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Different case studies fundamental of nursing

Respiratory Case Study

D.Z is a 62-year old man, admitted at 1600 to a medical floor with a diagnosis of acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD). His past medical history includes hypertension and type 2 diabetes. He has had pneumonia yearly for the past 3 years and has been a two-pack- a-day smoker for 38 years. His current medications include enalapril (Vasotec), hydrochlorothiazide (HCTZ), metformin (Glucophage), and fluticasone/salmeterol (Advair). He appears anxious and has difficulty breathing at rest. D. Z seems irritable and anxious; he C/O of sleeping poorly and states that lately he feels tired most of the time. He reports productive cough with thick yellow-green sputum. You auscultate decreased breath sounds, expiratory wheezes, and coarse crackles in both bilateral anterior and posterior lower lobes. His vital signs are: 162/84, 124, 36, 102 degrees and SPO2 88%.

Doctor’s orders:

Diet as tolerated

Out of bed with assistance

Oxygen to keep SPO2 above 90%

D5W at 50ml/hr.

ECG monitoring

Arterial Blood Gases (ABG) in the AM

CBC with differential now

BMP now

CXR daily

Sputum culture

Albuterol 2.5mg and ipratropium 250mcg nebulizer treatment STAT