Respiratory System Case Study

 
 
 
   
           
     

You are the RN on the nursing unit at Hospital. It is 7:30am.

After listening to nursing report, you decide to start your assessment rounds with Mr. Collins, age 74 who “had a rough night”. He was admitted yesterday for IV antibiotic therapy for the medical diagnosis of pneumonia. The night nurse says he has a fever of 99(ax) and restless night.

You enter his room and can hear coughing. He is awake and head of bed is elevated at least 45 degrees…

Entering the room, immediately you are OBSERVING & LISTENING for signs that would indicate respiratory distress (airflow obstruction and poor ventilation) and require immediate intervention?

Chief complaint: increased trouble breathing and a change in his cough

Significant history pertinent to his RESPIRATORY system includes:
COPD (emphysema and chronic bronchitis) diagnosed 6 years ago and treated with multiple medications.

He has seasonal allergies and is a current smoker with a 60 pack year smoking history (1 pack per day since he was 14 years old) who is “cutting down” and reports ½ pack per day for past 3 months.

 

Vital Signs: Temp.99 ax Pulse- 98 RR- 22 BP: 156/90 Weight (5’10”. Wt: 140 lbs)