Running head: NURS108 RESPIRATORY CASE STUDY 1
NURS108 Respiratory Case Study
Madison Dull
Schoolcraft College
, NURS108 RESPIRATORY CASE STUDY 2
NURS108 Respiratory Case Study
PATIENT NAME AGE
Russell Cole-Smith 67
MEDICAL DIAGNOSIS ALLERGIES CODE STATUS
Community Acquired Pneumonia NONE FULL
ABNORMAL NURSING ASSESSMENT FINDINGS, PATHOPYSIOLOGY, CITATION
Respiratory: Patient experiencing dyspnea, labored breathing, tachypneic, crackles in BLL,
nonproductive cough, receiving oxygen via nasal cannula 2L with a O2% of 89% and turned up
to 4L with no response. The infection causes the alveoli to become inflamed and fill up with
fluid or pus. This is why crackles are heard in the lungs. Due to this, it can make it hard for the
oxygen that is breathed in reach the bloodstream. This leads to symptoms of cough, fever,
chills, and trouble breathing (American Lung Association, 2024).
Cardiac: tachycardia, blood pressure decreased, +1 weak pule in RLE and LLE. Blood enters
the circulation system and passes through an under-ventilated area which then travels to the left
side of the heart. This blood is poorly oxygenated. The combination of oxygenated and
unoxygenated blood results in arterial hypoxemia (Hinkle et al., 2021, p.534)
GI: bowel sounds are hypoactive, not passing flatus. Absent and sluggish bowel sounds can be
a symptom of severe pneumonia (Gatta et al., 2024).
GU: Urine is amber in color. Urine in a light-yellow color is an indication of being hydrated.
However, urine that is darker or an amber color can indicate the patient is mildly dehydrated
and needs fluids (Wojcik, 2019).
Neurologic: Patient is lethargic, A/O X3 (person, place, and time), poor
attention/concentration. Glasgow Coma Scale: dropped from a 15 to 13. When a patient is
diagnosed with pneumonia, the patient is assessed for delirium. Delirium can be related to
hypoxemia, fever, dehydration, sleep deprivation, or developing sepsis. (Hinkle et al., 2021,
p.544)
Integument: pallor, hot, skin turgor recoils slowly. Excessive sweating and clammy skin is a
common symptom from fever and inflammation. An increased respiratory rate leads to an
increase in fluid loss during exhalation and can lead to dehydration. Therefore, unless
contraindicated, increase fluid intake (Hinkle et al., 2021, p.543).
DIAGNOSTIC TESTS/LABS
Lab Analysis What is causing the abnormal value (pathophysiology) &
Citation (no explanation needed for normal values)
WBC High –12 An increased count is an indication that bacterial infection like
pneumonia could be present (File, 2024).
HGB Low – 10.6 Red blood cells carry oxygen in the body. With a low level
HGB, it means the body is not getting enough oxygen, which is
due to an illness or disease (Cleveland Clinic Medical, 2022).
NURS108 Respiratory Case Study
Madison Dull
Schoolcraft College
, NURS108 RESPIRATORY CASE STUDY 2
NURS108 Respiratory Case Study
PATIENT NAME AGE
Russell Cole-Smith 67
MEDICAL DIAGNOSIS ALLERGIES CODE STATUS
Community Acquired Pneumonia NONE FULL
ABNORMAL NURSING ASSESSMENT FINDINGS, PATHOPYSIOLOGY, CITATION
Respiratory: Patient experiencing dyspnea, labored breathing, tachypneic, crackles in BLL,
nonproductive cough, receiving oxygen via nasal cannula 2L with a O2% of 89% and turned up
to 4L with no response. The infection causes the alveoli to become inflamed and fill up with
fluid or pus. This is why crackles are heard in the lungs. Due to this, it can make it hard for the
oxygen that is breathed in reach the bloodstream. This leads to symptoms of cough, fever,
chills, and trouble breathing (American Lung Association, 2024).
Cardiac: tachycardia, blood pressure decreased, +1 weak pule in RLE and LLE. Blood enters
the circulation system and passes through an under-ventilated area which then travels to the left
side of the heart. This blood is poorly oxygenated. The combination of oxygenated and
unoxygenated blood results in arterial hypoxemia (Hinkle et al., 2021, p.534)
GI: bowel sounds are hypoactive, not passing flatus. Absent and sluggish bowel sounds can be
a symptom of severe pneumonia (Gatta et al., 2024).
GU: Urine is amber in color. Urine in a light-yellow color is an indication of being hydrated.
However, urine that is darker or an amber color can indicate the patient is mildly dehydrated
and needs fluids (Wojcik, 2019).
Neurologic: Patient is lethargic, A/O X3 (person, place, and time), poor
attention/concentration. Glasgow Coma Scale: dropped from a 15 to 13. When a patient is
diagnosed with pneumonia, the patient is assessed for delirium. Delirium can be related to
hypoxemia, fever, dehydration, sleep deprivation, or developing sepsis. (Hinkle et al., 2021,
p.544)
Integument: pallor, hot, skin turgor recoils slowly. Excessive sweating and clammy skin is a
common symptom from fever and inflammation. An increased respiratory rate leads to an
increase in fluid loss during exhalation and can lead to dehydration. Therefore, unless
contraindicated, increase fluid intake (Hinkle et al., 2021, p.543).
DIAGNOSTIC TESTS/LABS
Lab Analysis What is causing the abnormal value (pathophysiology) &
Citation (no explanation needed for normal values)
WBC High –12 An increased count is an indication that bacterial infection like
pneumonia could be present (File, 2024).
HGB Low – 10.6 Red blood cells carry oxygen in the body. With a low level
HGB, it means the body is not getting enough oxygen, which is
due to an illness or disease (Cleveland Clinic Medical, 2022).
