Respiratory Disorders 2
Case Study 23
Name: Class: NUR 3463 Acute Care Date: 07.29.18
Group Members:
Scenario
C.K.'s sister has brought her 71-year-old brother to the primary care clinic; he came down with a
fever 2 days ago. She says he has shaking chills and a productive cough and he cannot lie down
to sleep because “he can't stop coughing.” After C.K. is examined, he is diagnosed with
community-acquired pneumonia (CAP) and admitted to your floor at 1130. The intern is busy
and asks you to complete your routine admission assessment and call her with your findings.
1. Identify four priority areas to include in your assessment.
Vital signs are the first priority -- especially oxygen saturation, but a full set of vitals is necessary
to determine the patient’s status
Lung sounds in all lung fields to help determine patency of airway -- also note patient’s rate and
depth of respirations
Color, temperature of extremities, and capillary refill in order to detect issues with perfusion
related to impaired gas exchange
Patient’s level of consciousness -- may be fatigued, confused due to lack of oxygenation and
body working harder to maintain -- poses a safety risk for the patient and should be assessed
immediately to prevent any potential accidents that could occur.
Case Study Progress
Your assessment findings are as follows: CK's vital signs (VS) are 154/82, 105, 32, 103° F (39.4°
C), Spo2 84% on room air. You auscultate decreased breath sounds and coarse crackles in the left
lower lobe anteriorly and posteriorly. His nail beds are dusky on fingers and toes. He has cough
productive of rust-colored sputum and complains of pain in the left side of his chest when he
coughs. He is a lifetime nonsmoker. Past medical history includes coronary artery disease and
myocardial infarction with a stent. He is currently on metoprolol (Lopressor), amlodipine
This study source was downloaded by 100000827506713 from CourseHero.com on 02-01-2023 05:34:59 GMT -06:00
https://www.coursehero.com/file/34938387/CAP-Case-Study-072918docx/
Case Study 23
Name: Class: NUR 3463 Acute Care Date: 07.29.18
Group Members:
Scenario
C.K.'s sister has brought her 71-year-old brother to the primary care clinic; he came down with a
fever 2 days ago. She says he has shaking chills and a productive cough and he cannot lie down
to sleep because “he can't stop coughing.” After C.K. is examined, he is diagnosed with
community-acquired pneumonia (CAP) and admitted to your floor at 1130. The intern is busy
and asks you to complete your routine admission assessment and call her with your findings.
1. Identify four priority areas to include in your assessment.
Vital signs are the first priority -- especially oxygen saturation, but a full set of vitals is necessary
to determine the patient’s status
Lung sounds in all lung fields to help determine patency of airway -- also note patient’s rate and
depth of respirations
Color, temperature of extremities, and capillary refill in order to detect issues with perfusion
related to impaired gas exchange
Patient’s level of consciousness -- may be fatigued, confused due to lack of oxygenation and
body working harder to maintain -- poses a safety risk for the patient and should be assessed
immediately to prevent any potential accidents that could occur.
Case Study Progress
Your assessment findings are as follows: CK's vital signs (VS) are 154/82, 105, 32, 103° F (39.4°
C), Spo2 84% on room air. You auscultate decreased breath sounds and coarse crackles in the left
lower lobe anteriorly and posteriorly. His nail beds are dusky on fingers and toes. He has cough
productive of rust-colored sputum and complains of pain in the left side of his chest when he
coughs. He is a lifetime nonsmoker. Past medical history includes coronary artery disease and
myocardial infarction with a stent. He is currently on metoprolol (Lopressor), amlodipine
This study source was downloaded by 100000827506713 from CourseHero.com on 02-01-2023 05:34:59 GMT -06:00
https://www.coursehero.com/file/34938387/CAP-Case-Study-072918docx/
