CASE STUDIES:
STUDENT COPY
Case Study # 1. A 59 year old black female is admitted at midnight with a diagnosis of
Chest Pain. She complains of a squeezing type pain across her chest and into her left jaw
area. Vital signs are: Blood Pressure-200/110; Pulse-128 beats per minute; Respirations26 per minute; Temperature-99.8; Saturation of Oxygen-86% on room air; pain level 9/10.
During your initial assessment she is rubbing her mid-chest, grimacing and is
diaphoretic. The pain has been occurring intermittently throughout the evening and
night. Her color is pale except around her lips which are bluish. Cardiac auscultation
reveals a rapid regular rhythm and a murmur, no pulse deficit. She has never had this
pain before. Lungs sounds are crackles in both bases with clear upper lobes. She is
afraid she is going to die. Per standing orders, a nurse administers & administers
Nitroglycerine 0.4mg sublingually; applies cardiac electrodes for continuous cardiac
monitoring; obtains an electrocardiogram; places a peripheral intravenous catheter with
saline lock; positions patient in low Fowlers.
On assessment, vital signs are Blood Pressure-180/95; Pulse-108 beats per minute;
Respirations- 22 per minute; Temperature-99.0; Saturation of Oxygen-90% on 2 liters per
minute; Pain level 8/10. She says her chest pain hasn’t changed. Heart and lung sounds
are unchanged. Color is pale without previous blue changes.
Activity: Using Tanner Model- Use the data in the case study to write 2 problems and at
least 4 interventions for each problem.
For Group Discussions:
1. What health history information would the nurse assess after the patient's pain is gone?
2. What abnormalities are present in the patient's vital signs (first set)?
3. A provider orders Aspirin 81 mg x 3 tabs by mouth chewing. What Is the rationale for this
order?
4. A nurse would expect the provider to order what type of medication if the patient has
congestive heart failure?
5. The nurse administers one nitroglycerin tablet sublingually.
A. What will this medication do for this patient?
B.What side effects will the nurse have to assess for and manage?
C.How many doses of Nitroglycerin can be given and within what time period?
D. The pain 1 assessment must be conducted before and after each dose. The desired
outcome is for the pain to decrease.
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Case Study # 2. A 55- year old African American male client presents to the Emergency
Department (ED). When determining the chief complaint, the client informs the nurse that
“I have shortness of breath that started about an hour ago.” The patient informs the
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nurse that he has a history of asthma and that during today’s attack, his Proventil
inhaler “didn’t seem to help.”
GROUP DISCUSSION:
1. What information would be most helpful for the nurse to obtain regarding this patient’s health
history and history of present illness?
2. What are some general assessment findings that indicate the patient is experiencing
respiratory distress?
3. How should the nurse proceed with the physical examination of this patient? What is the
priority of the physical exam?
4. What are adventitious sounds? Would the nurse expect to find adventitious sounds in this
client? If so, which ones would most likely be present?
5. What notes/tones would the nurse expect to find with percussion of the thorax in this client?
6. What other systems are affected by the respiratory system? How might the nurse assess
these systems and what findings would the nurse expect to find?
Case Study #3. Patient T is a man, 84 years of age, who resides in a long-term care
facility. He has been diagnosed with congestive heart failure, hypertension, arthritis, and
hyperlipidemia and has a history of two myocardial infarctions (eight and two years
previously). He requires minimal assistance with his activities of daily living and remains
ambulatory with a cane.
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His usual medications are:
● Metoprolol ER: 50 mg daily
● Aspirin: 325 mg daily
● Omeprazole: 20 mg daily
● Lisinopril: 10 mg daily
● Furosemide: 40 mg every day
● Potassium chloride: 20 mEq twice daily
● Atorvastatin: 20 mg daily
● Acetaminophen: 650 mg twice daily
● Tramadol: 50 mg, as needed
● Multivitamin
At baseline, he takes 10 medications/supplements. Patient T is transferred to the
emergency department for increased shortness of breath. He is diagnosed with
bronchitis and spends 24 hours in the hospital for observation before being transferred
back to the long-term care facility for ongoing care.
At the care facility, the receiving practitioner reviews the medication list from the
hospital:
● Levofloxacin: 500 mg daily
● Prednisone: 20 mg daily
● Tiotropium bromide, inhalation: One puff daily
● Levalbuterol tartrate, inhalation solution for nebulizer: As needed for shortness of breath
● Promethazine: 25 mg every six hours as needed
● Haloperidol: 1 mg every four hours as needed
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● Bisacodyl: 10 mg every day as needed.
Patient T is currently prescribed 17 drugs. Physical assessment reveals an elderly
debilitated man who is in no acute distress (Table 3). He is alert and oriented and
answers questions appropriately. His intake of food and fluids has been poor since his
return from the hospital, and he is using oxygen per nasal cannula at 2 L/minute.
(TABLE 3) RESULTS OF PATIENT T'S PHYSICAL EXAM Parameter Measurement
Blood pressure 112/62 mm Hg
Temperature: 97.8° F
Heart rate : 92 beats per minute
Respiration rate: 22 breaths per minute
Height 5 feet 9 inches (175 cm)
Weight: 65.3 kg (144 pounds) (usual: 154 pounds)
Heart sounds: S1, S2 with 2/6 systolic ejection murmur
Lung sounds: Few expiratory wheezes noted anteriorly
Extremities No significant edema Abdomen Unremarkable
STUDENT ACTIVITY: 1. Medication Reconciliation- What are the clinical indications for each
medication? What medications are ordered in the hospital that are no longer necessary?
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