NR324 I-HUMAN CASE STUDY AMIR PATEL – AN 89-
YEAR-OLD MALE WITH ACUTE DELIRIUM SECONDARY TO
PNEUMONIA AND DEHYDRATION A COMPLETE SBAR-
GUIDED NURSING CASE ANALYSIS
Amir Patel is an 89-year-old male brought to the
Emergency Department by his wife after she noted
a sudden change in his mental status over the past
24 hours. She observed him putting his shirt on
,backwards, reading the newspaper upside down,
and not responding to her as he typically would. The
patient also presented with a cough, shortness of
breath, and fever (100.1–100.2°F).
Upon assessment, Amir is alert but disoriented
(A&O x2) , with significant lethargy and confusion.
Vital signs reveal tachycardia (HR 105
bpm), hypotension (BP 86/56–104/68
mmHg), tachypnea (RR 26 breaths/min),
and hypoxemia (SpO2 90% on room air). Physical
examination is notable for tenting skin over the
clavicle and dry, cracked lips, indicating severe
dehydration. Abnormal lung sounds confirm a lower
respiratory infection.
Diagnostic findings include an elevated WBC
count, elevated BUN, dark amber urine, and
an abnormal chest X-ray consistent with
pneumonia. The patient's history is significant
for Alzheimer's dementia, hypertension,
osteoarthritis, hearing impairment (uses hearing
aid), and mobility impairment (uses a walker). He
experienced a fall approximately four months ago,
placing him at high risk for falls.
,The primary diagnoses are Pneumonia, Acute
Dehydration, and Acute Delirium secondary to
infection and dehydration. The patient is at risk
for Sepsis and Acute Kidney Injury due to
hypotension and dehydration. Key nursing priorities
include managing impaired gas exchange (O2
therapy, bronchodilators, positioning), ensuring
patient safety (1:1 sitter, fall precautions), correcting
fluid volume deficit (IV fluids, strict I&Os),
and administering antibiotics to treat the infection.
The interprofessional plan includes IV antibiotics
(Levaquin 500 mg IV Q12h), bronchodilators
(Ipratropium/Albuterol nebulizer Q4H) , IV fluids
(Normal Saline 0.9% at 75 mL/hr) , DVT prophylaxis
(Enoxaparin 40 mg SQ daily) , and supplemental
oxygen (2L nasal cannula) . A 1:1 sitter has been
implemented to manage his altered mental status
and prevent injury.
This case emphasizes the critical assessment of
subtle signs of infection in elderly patients,
the importance of family collateral history, and
the interprofessional management of acute
decompensation in a patient with underlying
dementia.
, Part 1: Patient Bio Data & Initial Data Gathering
Category Details
Name Amir Patel
Age 89 years old
Gender Male
Ethnicity [Specified in case]
Source Wife (primary historian)
Patient has altered mental status; wife is reliabl
Reliability
historian
Allergies [To be confirmed]
Reason for Encounter: Wife called EMS after noting
lethargy, odd behaviors (putting shirt on backwards,
reading newspaper upside down, not responding as
usual)
Chief Complaint: "Acute confusion, fever, and
cough"
YEAR-OLD MALE WITH ACUTE DELIRIUM SECONDARY TO
PNEUMONIA AND DEHYDRATION A COMPLETE SBAR-
GUIDED NURSING CASE ANALYSIS
Amir Patel is an 89-year-old male brought to the
Emergency Department by his wife after she noted
a sudden change in his mental status over the past
24 hours. She observed him putting his shirt on
,backwards, reading the newspaper upside down,
and not responding to her as he typically would. The
patient also presented with a cough, shortness of
breath, and fever (100.1–100.2°F).
Upon assessment, Amir is alert but disoriented
(A&O x2) , with significant lethargy and confusion.
Vital signs reveal tachycardia (HR 105
bpm), hypotension (BP 86/56–104/68
mmHg), tachypnea (RR 26 breaths/min),
and hypoxemia (SpO2 90% on room air). Physical
examination is notable for tenting skin over the
clavicle and dry, cracked lips, indicating severe
dehydration. Abnormal lung sounds confirm a lower
respiratory infection.
Diagnostic findings include an elevated WBC
count, elevated BUN, dark amber urine, and
an abnormal chest X-ray consistent with
pneumonia. The patient's history is significant
for Alzheimer's dementia, hypertension,
osteoarthritis, hearing impairment (uses hearing
aid), and mobility impairment (uses a walker). He
experienced a fall approximately four months ago,
placing him at high risk for falls.
,The primary diagnoses are Pneumonia, Acute
Dehydration, and Acute Delirium secondary to
infection and dehydration. The patient is at risk
for Sepsis and Acute Kidney Injury due to
hypotension and dehydration. Key nursing priorities
include managing impaired gas exchange (O2
therapy, bronchodilators, positioning), ensuring
patient safety (1:1 sitter, fall precautions), correcting
fluid volume deficit (IV fluids, strict I&Os),
and administering antibiotics to treat the infection.
The interprofessional plan includes IV antibiotics
(Levaquin 500 mg IV Q12h), bronchodilators
(Ipratropium/Albuterol nebulizer Q4H) , IV fluids
(Normal Saline 0.9% at 75 mL/hr) , DVT prophylaxis
(Enoxaparin 40 mg SQ daily) , and supplemental
oxygen (2L nasal cannula) . A 1:1 sitter has been
implemented to manage his altered mental status
and prevent injury.
This case emphasizes the critical assessment of
subtle signs of infection in elderly patients,
the importance of family collateral history, and
the interprofessional management of acute
decompensation in a patient with underlying
dementia.
, Part 1: Patient Bio Data & Initial Data Gathering
Category Details
Name Amir Patel
Age 89 years old
Gender Male
Ethnicity [Specified in case]
Source Wife (primary historian)
Patient has altered mental status; wife is reliabl
Reliability
historian
Allergies [To be confirmed]
Reason for Encounter: Wife called EMS after noting
lethargy, odd behaviors (putting shirt on backwards,
reading newspaper upside down, not responding as
usual)
Chief Complaint: "Acute confusion, fever, and
cough"
