Suggestive Case Studies

A normal respiratory rate is between 12 & 20 breaths per minute, this can be recorded manually by using a clock. If you respiratory rate drops below the normal measurements

PHYSICAL EXAM: Temperature 98.6, Blood pressure 140/90. Pulse 110. Respirations 26. Her lungs are clear, showing mild signs of distress. Heart sounds are normal, irregular rhythm and bradycardia

PHYSICAL EXAM: Temperature 98.6, Blood pressure 140/90. Pulse 110. Respirations 26. Her lungs are clear, showing mild signs of distress. Heart sounds are normal, irregular rhythm and bradycardia noted. No edema noted in extremities. Patient skin is cool to touch, slightly clammy. EEG shows prolonged QRS wave, with ischemic ST changes and PVCs. Chest radiograph clear.

Hi Roseann. Good Job. Your Unit 7 Initial Post is very informative. Her verbal report of fatigue, bilateral lower lobe crackles, skin is cool to touch, +2 edema in bilateral ankles, and heart rate of 112 are signs and symptoms of congestive heart failure. Her medical history of high blood pressure and coronary artery disease could also lead to heart failure. My focus would be is to teach her with CHF symptom management and to prevent exacerbation. To avoid hospitalization I would educate and give her a list of preventable measures such as avoiding salts, measuring her weight every morning, and fluid restrictions. I would advise S.P to notify her doctor with weight gain over 2 pounds. Medication compliance is also important in managing her

HPI: Margaret Elliot is a 52-year-old Caucasian female that is presenting with shortness of breath that has recently worsen. Mrs. Elliot states that her problems began 20 years ago when she had bronchitis, which she consistently has 2-3 times a year. She said that her symptoms have been getting worse the last 2.5 month, but have severely worsen over the past three days. She states that it has been restricting her daily activities and has been troubling her while sleeping lying down. She states that her symptoms improve alittle when she takes her medications. She also states that her symptoms worsen when she tries to walk across the room

The higher her respiratory rate the more liters of oxygen needed to supply for the loss in her lungs. To get the minute ventilation you take the breaths per min times 500mL/breath and that gets your liters of oxygen per min.

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examination was remarkable for crackles at her right lung base. The examination of her cardiac,

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On Aril 25, 2012, L.M. was found to be increasingly fatigued, somnolent, and had shortness of breath accompanied with tachycardia as witnessed by the staff at the SNF.

Vital signs are a fundamental component of nursing care and indicate the body’s ability to maintain blood flow, regulate temperature and regulate oxygenate the body tissue. Taking vital signs are essential in revealing any sudden changes in the body, which could potentially indicate clinical deterioration of the patient.

S.R is a 69-year old man who presents to the clinic because his “wife complains that his snoring is difficult to live with.”

The issue of consistency is raised when discussing how to ensure assessments are comprehensive, complete and that the data is recorded using the same guidelines as other nurses. To enable consistency of assessment, the same nurse should be taking the observations of a patient for the duration of a shift (Moore, 2007). This ensure that the interpretation of results don’t differ each time the vital signs are done. It also allows the nurse to detect subtle changes in the patients state that may not have been written down. For example, in most clinical environments the respiration rate is recorded as just a number, and the rhythm, degree of effort, quality of breathing and evidence of wheezing or other abnormal breathing sounds are not recorded. The rate may stay the same over a period of time while other aspects of respiration may change, and this is something that a nurse is more likely to notice if they have assessed that patient before. During handover, a nurse should tell the next nurse looking after their patients how they took observations and detail what tools they used to ensure consistency is maintained.

As Jane was presenting with a symptom of a life threatening event it was important that treatment was immediate. Priority was initially made from assessment of the airways, breathing and circulation, level of consciousness and pain. Jane’s respirations on admission were recorded at a rate of 28 breaths per minute, she looked cyanosed. Jane’s other clinical observations recorded a heart rate of 105 beats per minute (sinus tachycardia), blood pressure (BP) of 140/85 and oxygen saturation (SPO2) on room air 87%. It is important to establish a base line so that the nurse is altered to sudden deterioration in the patient’s clinical condition. Jane’s PEWS score (Physiological Early Warning Score) was 4 and indicated a need for urgent medical attention (BTS 2006). Breathing was the most obvious issue and was the immediate priority.

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