Name: Anaise Ikama
Date: May 21, 2007
Case Study # 1
PN Program
LaGuardia Community College
Spring I 2007
Mr. Green Jeans, 74 years old, came to the hospital two days ago with complaint of chest pain, weakness, and a
high temperature. Mr. Green Jeans is a retired bookbinder who resides in a mobile home with his wife. Both have
preexisting health conditions that put them at risk for pneumonia. Mr. Green Jeans is a diabetic and takes insulin
twice daily. Mr. Green Jeans has a history of alcohol abuse but at present is not drinking. Both individuals are heavy
smokers and have been for more than fifty years. Currently they are not using any external support systems outside the
home. Mrs. Jeans performs most of the household duties and grocery shops once each week with the help of her
daughter. Mr. Green Jeans used to help with the housework, and he loves to tinker in the garden, however, lately he
has been unable to do either. His wife states, “All he seems to be able to do is sit in the chair and watch TV.”
Bernard Brick is a student practical nurse assigned to his first hospital-based clinical experience. Bernard has had
some experience in health assessment and client teaching related to health promotion activities from his recent clinical
rotation in a nursing home. In a previous clinical experience clients were motivated to adjust their at-risk health
behaviors, such as smoking or poor diet. Bernard feels confident when he arrives in the clinical area in the morning
because Mr. Green Jeans has similar health needs to the clinical experiences he has had. However, when Bernard goes
to meet Mr. Green Jeans and perform his morning assessment; he is overwhelmed. This client is in a great deal of
respiratory distress. It seems as if every breath is a struggle for him. Everything that Bernard planned to do seems less
important. The client is extremely anxious. His wife is at his side anticipating Bernard’s every move and demanding
some action.
On a separate sheet please type your responses to these questions and turn in with this page on the top. Make
sure your name is on both pages. Place one staple in the top left corner.
What signs and symptoms would you expect to see?
1. Underline data that is abnormal
2. If Mr. Green Jeans has absent breath sounds what will you hear on auscultation?
3. When auscultating Mr. Green Jeans’ breath sounds in his present condition, what would you expect to
hear?
4. Give one example of a set of vital signs you might expect to see for this client.
5. List a priority nursing diagnosis and give 2 interventions with rationales for that diagnosis.
Answer to Questions in Case Study # 1
1. What signs and symptoms would you expect to see?
Signs and symptoms that I would expect to see in Mr. Green Jeans are:
-
-
High in body temperature
Anxiety of hypoxia
Increase in respiration
Difficulty exhaling
Chest pain
Weakness
Shortness of breath, dyspnea
2. Underline data that is abnormal
See underlined words and statements above.
3. If Mr. Green Jeans has absent breath sounds, what will you hear on auscultation?
If Mr. Green Jeans’ breath sounds were absent, no sound would have been heard at the baseline during auscultation.
4. When auscultating Mr. Green Jeans’ breath sounds in his present condition, what would you expect to hear?
When auscultating Mr. Green Jeans’ breath sounds in his present condition, bubbling sound will be heard as inhaled
air will come in contact with secretion in upper airway.
5. Give one
-
example of a set of vital signs you might expect to see
Increase in body temperature (104)
Increase in blood pressure (150/92)
Increase in respiration (22 beats per minute)
Increase in palpation of pulse (120)
for this client.
6. List a priority nursing diagnosis and give 2 interventions with rationales for that diagnosis.
Nursing diagnosis
Nursing interventions
Rationales
Ineffective airway clearance related to
physiologic
effects
of
pneumonia
as
evidenced by chest pain, respiratory distress,
increase in body temperature and difficulty
exhaling.
1.Administer supplementhumidified oxygen as prescribed
1 Administering oxygen to the
client will decrease respiratory
effort.
2. Put the client into Fowler’s
position
2 Putting the client into Fowler’s
position will improve his or her
lung’s expansion.