PATIENT ASSIGNMENT: RB is a 63-year-old male admitted to the nursing unit yesterday with acute exacerbation of chronic obstructive pulmonary disease (COPD). He has a history of HTN. He has NKDA, is a full code, and is on a low-salt diet. His Braden score is 22 and his activity is as tolerated. He is married with three grown children and four grandchildren. He works full-time as a CPA in an accounting firm. INITIAL ASSESSMENT: 0700: VS: T 38.9 C (102 F), BP 142/84, P 78 and regular, R 22 and labored, O2 saturation 93% on 2 L O2 per NC. Denies pain. A&Ox4, DOE, wheezes, and crackles are audible on auscultation, productive cough, and greenish sputum. Complaint of chest tightness. The apical pulse is 80 bpm. The abdomen is soft and non-tender with BS x 4. Urine is clear and light yellow. MAE. Pedal pulses are 1+ bilaterally. Capillary refill >3 seconds. RB has a 20-gauge saline lock in his left hand. He becomes winded with any activity and requires short breaks while completing his activities of daily living (ADL). His medications include prednisolone 40 mg PO q AM, levofloxacin 750 mg IV daily, hydrochlorothiazide 12.5 mg PO daily, and captopril 25 mg PO bid. Orders include respiratory therapy 3x/day, falls precautions, O2-2 L per NC to maintain >92% sat, CBC, BMP, and arterial blood gases (ABGs) daily and PRN, Accu-Check q 8 hr, saline lock, daily weights, I&O. 11. Identify at least four assessment findings and one medication order indicating that RB’s COPD exacerbation is the result of one of the most common causative factors? ASSESSMENT UPDATE: While you are interviewing RB about his health history, he reports smoking one pack of cigarettes a day for 40 years and having tried to quit repeatedly without success. He states, “ I would really like to break this habit. I know it is killing me!” His 08000 lab results, including ABGs after 10 minutes on RA are as follows: ABG pH 7.24 PACO2 56 mm Hg HCO3 24 mEq/L PaO2 58 mm Hg 12. Which BMP and CBC findings are abnormal? Provide a rationale for each abnormal result. 13. What are the normal ABG levels for pH, PACO2, and HCO3? 14. What do RB’s arterial blood gas results indicate? Provide a rationale for your answer and complete the lab values/diagnostic test results area of your CCM for RB.

PATIENT ASSIGNMENT: RB is a 63-year-old male admitted to the nursing unit yesterday with acute exacerbation of chronic obstructive pulmonary disease (COPD). He has a history of HTN. He has NKDA, is a full code, and is on a low-salt diet. His Braden score is 22 and his activity is as tolerated. He is married with three grown children and four grandchildren. He works full-time as a CPA in an accounting firm. INITIAL ASSESSMENT: 0700: VS: T 38.9 C (102 F), BP 142/84, P 78 and regular, R 22 and labored, O2 saturation 93% on 2 L O2 per NC. Denies pain. A&Ox4, DOE, wheezes, and crackles are audible on auscultation, productive cough, and greenish sputum. Complaint of chest tightness. The apical pulse is 80 bpm. The abdomen is soft and non-tender with BS x 4. Urine is clear and light yellow. MAE. Pedal pulses are 1+ bilaterally. Capillary refill >3 seconds. RB has a 20-gauge saline lock in his left hand. He becomes winded with any activity and requires short breaks while completing his activities of daily living (ADL). His medications include prednisolone 40 mg PO q AM, levofloxacin 750 mg IV daily, hydrochlorothiazide 12.5 mg PO daily, and captopril 25 mg PO bid. Orders include respiratory therapy 3x/day, falls precautions, O2-2 L per NC to maintain >92% sat, CBC, BMP, and arterial blood gases (ABGs) daily and PRN, Accu-Check q 8 hr, saline lock, daily weights, I&O. 11. Identify at least four assessment findings and one medication order indicating that RB’s COPD exacerbation is the result of one of the most common causative factors? ASSESSMENT UPDATE: While you are interviewing RB about his health history, he reports smoking one pack of cigarettes a day for 40 years and having tried to quit repeatedly without success. He states, “ I would really like to break this habit. I know it is killing me!” His 08000 lab results, including ABGs after 10 minutes on RA are as follows: ABG pH 7.24 PACO2 56 mm Hg HCO3 24 mEq/L PaO2 58 mm Hg 12. Which BMP and CBC findings are abnormal? Provide a rationale for each abnormal result. 13. What are the normal ABG levels for pH, PACO2, and HCO3? 14. What do RB’s arterial blood gas results indicate? Provide a rationale for your answer and complete the lab values/diagnostic test results area of your CCM for RB.

Case Studies In Health Information Management

3rd Edition

ISBN:9781337676908

Author:SCHNERING

Publisher:SCHNERING

Chapter1: Data Content, Structure, And Standards

Section: Chapter Questions

Problem 1.25.1C

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