Posted: September 20th, 2022

Jackie Frost is a 74-year old male to female

Case study ~ UNIT 2
Part I: Initial Nursing Assessment
Jackie Frost is a 74-year old male to female (transgender) with a past medical history of benign prostatic hyperplasia (BPH), Multiple Myeloma (currently in remission), Myasthenia Gravis. She was prescribed a 5-day course of dexamethasone and a Salbutamol inhaler by her family physician for respiratory support as she was experiencing shortness of breath after she tested positive for COVID-19. Mrs. Frost is triple vaccinated, last dose December. 2021
Jackie presents to the emergency department today with increasing shortness of breath, fatigue, poor PO intake, fever and chills on and off for the past week. Patient is mouth breathing, nasal flaring and speaking only 1-2 words at a time, and has rapid shallow breathing. Jackie has a productive weak cough with yellow/white phlegm sputum. On initial vital signs: BP 89/52, HR: 109/min, RR 32/min, T 37.4, SpO2 85% on Room air. Patient expressed that she feels like she cannot catch her breath.
Personal/Social History:
Jackie is retired and lives at home with her husband. Her two adult children live out of province. She has recently attended a wedding and has been exposed to COVID-19. One week after being exposed, the PCR test came back positive. She is active in her community and has a membership at the community golf course. Since she has been dealing with changes in her health and is currently in remission, she has been healthy and tried to avoid big events as Jackie is immunocompromised. She expresses to you that she currently should have stayed home and is feeling guilty and frustrated that she even went to the wedding. No history of alcohol, smoking, or drug abuse.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Data from Present Problem: Clinical Significance:

RELEVANT Data from Social History: Clinical Significance:

Jackie is transferred to the ED and quickly brought to a room. You introduce yourself, and collect the following clinical data:

Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 37.9 C (Temporal) Provoking/Palliative: Denies
P: 105/min Quality: Denies
R: 33/min Region/Radiation: Denies chest pain
BP: 82/48 (MAP =59) Severity: 0/10
O2 sat: 85% room air Timing: N/A

Current Assessment:
GENERAL SURVEY: Appears tired and in mild distress from trying to catch breath. Her husband reports that her appetite has decreased over the past week.
NEUROLOGICAL: Alert & oriented to person, place, time (x3); muscle strength 5/5 in both upper and lower extremities bilaterally.
HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally. Lips dry and oral mucosa sticky.
RESPIRATORY: Breath sounds clear to upper lobes, diminished bilaterally with course crackles to both bases. Moderate & labored work of breathing on room air. Persistent weak productive cough with sputum.
CARDIAC: Pale. Heart sounds regular S1, S2 and tachycardic, pulses weak on palpation at radial/pedal landmarks, cap refill 4-5 seconds. No JVD noted at 30-45 degrees.
ABDOMEN: Abdomen round, soft, and non-tender. BS + in all 4 quadrants.
GU: Voiding frequently with urgency, urine clear/yellow-amber colored
INTEGUMENTARY: Skin warm, dry, intact. No clubbing of nails. Skin integrity intact, no tenting present.
What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Assessment based off priority***)
RELEVANT Assessment Data: Clinical Significance:

Clinical Judgement:

1) What priority diagnostic/laboratory tests would you think the MRHP would order and why? (Only list 2 that stand out and take priority)

2) Which system is your focus assessment?

What nursing interventions should you provide first based off of your initial assessment?

3) The MRHP orders a 1L bolus STAT to be given as fast as possible. Which IV solution do you think will be ordered (Hypotonic, Isotonic, Hypertonic) Provide rationale.

Part II: Interpreting Diagnostic Data:
The primary care provider orders the following diagnostic tests: chest x-ray & ABG

Chest X-Ray Report reads:

Findings: The Cardiomediastinal silhouette and pulmonary vasculature are within normal limits and in size. The lungs show no signs of pneumothorax. Trachea unremarkable.

-Mild/moderate right/left pleural effusion seen on image
-Consolidation present on both right and left side (Right lower lobe > left)

Radiology: Chest X-ray
Results: Clinical Significance:
Right lower lobe pneumonia with pulmonary edema -Accumulation of fluid in the extravascular spaces of the lung. Confirms the presence of pulmonary edema that may be the cause of respiratory issues and poor tissue perfusion.

Right Lower Lobe pneumonia: Is characterized by inflammatory exudate within the intra-alveolar space resulting in consolidation that effects a large continuous area of the lobe of a lung.

Complications: respiratory and metabolic acidosis, respiratory failure, cardiac or respiratory arrest

S&S: decreased SpO2 sats, productive cough, course crackles, tachycardia, poor perfusion, hypotension

Complete Blood Count (CBC)
WBC HGB PLTs
% Neuts
Bands
Current: 3.4 133 150 2.3 0
RELEVANT Lab(s): Clinical Significance: TREND: Low/High/WNL
WBC (4.5 – 11)
Hgb (120 – 160)
PLTs (150 – 400)

% Neuts(2.9 – 9.0)
Band (0 – 6%)
Basic Metabolic Panel (BMP)
Na (135—145 mEq/L) K (3.5—5.0 mEq/L) Glucose Creat. (0.6—1.2 mg/dL)
Current: 146 4.0 5.5 0.96
Which lab values are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

The doctor orders a STAT Arterial Blood Gas (ABG):
1) As the bedside nurse who would you communicate with to ensure that the appropriate member of the multidisciplinary team is notified?

2) Which discipline completes the ABG test?

3) Why is an ABG performed?
ABG Results: What does this indicate
Lab Normal Range Results
pH 7.35—7.45 7.47
HCO3 22—26 17
PaCO2 35—45 32
O2 Saturation 92—100% 86%
Part III: Put it All Together to Think Like a Nurse
1. Interpreting all clinical data collected, what is the patient’s diagnosis?

2. What response system(lines of defense) do you think has been activated initially?

3. In your OWN words explain the pathophysiology of of the priority problem.

4. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (fill in the table below)
Nursing PRIORITY:
GOAL of Care:
Nursing Interventions: Rationale: Expected Outcome:

5. Provide rationale and expected outcomes on the following care provider orders

Care Provider Orders: Rationale: Expected Outcome:
Establish peripheral IV
Blood culture
IV Maintenance fluids 0.9% NaCL at 75cc/hr
Urine Analysis/Culture
Ceftriaxone IV 1 g every 12 hrs. over 30 minutes (due at 0800 as per MAR)
Vancomycin IV 1 g. every 12 hrs. over 60 minutes (Due at 0900)
Vitamin D 1000 i/units
Prednisone 50mg daily
Pantoprazole 40mg daily
Tamsulosin 0.4mg daily
Estrogen 8 mg daily

For the following six drugs: provide a classification of the each of the drugs and the mechanism of action.
Medication Classification Mechanism of Action

Ceftriaxone IV 1 g every 12 hrs.
Vancomycin IV 1 g. every 12
Vitamin D 1000 i/units
Prednisone 50mg daily
Pantoprazole 40mg daily
Tamsulosin 0.4mg daily
Estrogen 8 mg daily

Art of Nursing
Clinical Scenario:
Before you left for your breakfast break Mrs. Frost’s oxygen was set at 5L via nasal prongs, RR 26/min, SpO2 93%, BP 105/65. You return from break and your patients oxygen saturations are <90% and starting to drop. The patient can only speak one word at a time, nasal flaring and suprasternal and subcostal indrawing present, respirations are shallow and rapid. You get a saturation reading of 82%.
The patient asks you to phone and update her husband . She asks you “I am going to die”?
How do you respond to this and who do you notify as your patient is actively deteriorating…
Did you know? Transgender individuals may delay seeking healthcare when ill due to financial costs, fear of discrimination, or previous negative experiences within the healthcare system. According to Lambda Legal, transgender adults experience significantly higher rates of healthcare providers being unaware of their health needs, refusing to provide care, providing substandard care, or treating them poorly during provision of care than lesbian, gay, and bisexual adults.
Fill in the description to the following definitions:
• Transgender:
• Transwoman:
• Transman:
• Genderqueer and gender nonconforming:
• Cisgender:
• Sex assigned at birth:
• Gender:
• Gender expression:
• Gender identity:
• Sexual orientation:
• Gender transition:
• Coming out:
Nursing Considerations
Name five considerations you can do as a nurse to create a welcoming environment for transgender patients.

======
Example Case study Answer, Case Study Writing Guide, Study Notes:
RELEVANT Data from Present Problem: Clinical Significance:

Increasing shortness of breath, fatigue, poor PO intake, fever and chills on and off for the past week. – Indicates the presence of acute respiratory distress, possibly due to COVID-19 infection and/or exacerbation of pre-existing conditions such as Myasthenia Gravis.
Mouth breathing, nasal flaring, speaking only 1-2 words at a time, and rapid shallow breathing – Indicates respiratory distress and hypoxemia, which is a medical emergency that requires immediate intervention.
Productive weak cough with yellow/white phlegm sputum – Suggests possible respiratory infection or inflammation.
BP 89/52, HR: 109/min, RR 32/min, T 37.4, SpO2 85% on Room air – Indicates severe hypoxemia, tachycardia, and hypotension, which requires prompt medical attention.
Patient expressed that she feels like she cannot catch her breath – Indicates severe respiratory distress and hypoxemia, which requires immediate intervention.
RELEVANT Data from Social History: Clinical Significance:

Attended a wedding and has been exposed to COVID-19 – Indicates a potential source of infection for COVID-19.
Active in the community and has a membership at the community golf course – Suggests a possibility of exposure to other individuals and potential sources of infection.
Immunocompromised due to Myasthenia Gravis and recent history of Multiple Myeloma – Indicates a higher risk for developing severe COVID-19 infection and other complications.
RELEVANT Assessment Data: Clinical Significance:

O2 sat: 85% room air – Indicates severe hypoxemia, which requires prompt intervention.
Respiratory: Breath sounds clear to upper lobes, diminished bilaterally with course crackles to both bases. Moderate & labored work of breathing on room air. Persistent weak productive cough with sputum. – Suggests possible respiratory infection or inflammation, and indicates the presence of respiratory distress and hypoxemia.
Cardiac: Heart sounds regular S1, S2 and tachycardic, pulses weak on palpation at radial/pedal landmarks, cap refill 4-5 seconds. No JVD noted at 30-45 degrees. – Indicates signs of hypotension and poor perfusion, which require prompt intervention.
Clinical Judgement:

Based on the assessment data, the patient is experiencing severe respiratory distress and hypoxemia, likely due to COVID-19 infection and/or exacerbation of pre-existing conditions. Immediate intervention is required to address the patient’s hypoxemia, support her breathing, and stabilize her vital signs.

The priority diagnostic/laboratory tests that the MRHP may order include:
Arterial blood gas (ABG) to assess the patient’s acid-base balance, oxygenation, and ventilation status.
Chest X-ray to evaluate the lungs for signs of infection, inflammation, and fluid accumulation.
The focus of the assessment is on the respiratory system, as the patient is presenting with severe respiratory distress and hypoxemia.

The MRHP may order an isotonic IV solution such as Normal Saline (0.9% NaCl) for the 1L bolus, as it can expand the patient’s intravascular volume and improve tissue perfusion without causing fluid shifts that may exacerbate the patient’s pulmonary edema. Hypotonic and hypertonic solutions may cause fluid shifts and electrolyte imbalances that can worsen the patient’s condition.

Nursing interventions that should be provided first based on the initial assessment include:

Administering supplemental oxygen via a non-rebreather mask or high-flow nasal cannula to improve the patient’s oxygen saturation and relieve her hypoxemia.

Assessing and monitoring the patient’s respiratory rate, pattern, depth, and effort, as well as her oxygen saturation, blood pressure, heart rate, and level of consciousness, to detect any changes in her respiratory and hemodynamic status.

Helping the patient with positioning to optimize her breathing, such as elevating the head of the bed and encouraging deep breathing and coughing.

Administering medications as ordered, such as bronchodilators, antipyretics, and antibiotics, to relieve bronchospasm, reduce fever, and treat possible infections.

Initiating isolation precautions and wearing appropriate personal protective equipment (PPE) to prevent the spread of COVID-19 infection to other patients and healthcare providers.

Providing emotional support and reassurance to the patient and her family, as respiratory distress can be a frightening and stressful experience.

Collaborating with the healthcare team to facilitate prompt diagnostic and therapeutic interventions, such as obtaining ABG and chest X-ray results, consulting with a respiratory therapist, and considering transfer to a higher level of care if warranted.

Order | Check Discount

Tags: Case study answer, Jackie Frost is a 74-year old male to female, Write a paper page