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    MS CourseUnit9

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    Aria
    The document contains two questions regarding a patient case study. 1. For a patient with chest trauma and a chest tube, the nurse would assess airway patency, breathing patterns, vital signs, and lung sounds to monitor for changes. Increased shortness of breath could be due to problems like an allergic reaction or underlying heart/lung condition. The nurse would prepare for emergencies by ensuring early mobilization, pain control, fluid management and respiratory therapy. 2. For a patient with community acquired pneumonia, the nurse would monitor for manifestations like cough with colored mucus, fever, and breathing difficulties. The nurse would also assess for hypoxemia and its causes like bronchospasm and alveolar

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    MS CourseUnit9

    Uploaded by

    Aria
    2K views2 pages
    The document contains two questions regarding a patient case study. 1. For a patient with chest trauma and a chest tube, the nurse would assess airway patency, breathing patterns, vital signs, and lung sounds to monitor for changes. Increased shortness of breath could be due to problems like an allergic reaction or underlying heart/lung condition. The nurse would prepare for emergencies by ensuring early mobilization, pain control, fluid management and respiratory therapy. 2. For a patient with community acquired pneumonia, the nurse would monitor for manifestations like cough with colored mucus, fever, and breathing difficulties. The nurse would also assess for hypoxemia and its causes like bronchospasm and alveolar

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    The document contains two questions regarding a patient case study. 1. For a patient with chest trauma and a chest tube, the nurse would assess airway patency, breathing patterns, vital signs, and lung sounds to monitor for changes. Increased shortness of breath could be due to problems like an allergic reaction or underlying heart/lung condition. The nurse would prepare for emergencies by ensuring early mobilization, pain control, fluid management and respiratory therapy. 2. For a patient with community acquired pneumonia, the nurse would monitor for manifestations like cough with colored mucus, fever, and breathing difficulties. The nurse would also assess for hypoxemia and its causes like bronchospasm and alveolar

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    2K views2 pages

    MS CourseUnit9

    Uploaded by

    Aria
    The document contains two questions regarding a patient case study. 1. For a patient with chest trauma and a chest tube, the nurse would assess airway patency, breathing patterns, vital signs, and lung sounds to monitor for changes. Increased shortness of breath could be due to problems like an allergic reaction or underlying heart/lung condition. The nurse would prepare for emergencies by ensuring early mobilization, pain control, fluid management and respiratory therapy. 2. For a patient with community acquired pneumonia, the nurse would monitor for manifestations like cough with colored mucus, fever, and breathing difficulties. The nurse would also assess for hypoxemia and its causes like bronchospasm and alveolar

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    © All Rights Reserved
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    of 2

    AUBREY ROSE A.

    VIDON

    BSN 3Y1 - 2

    COURSE UNIT #9

    Answer the following questions base on the cited situation.

    1. You are caring for a 34-year-old patient who experienced blunt chest trauma in a motor
    vehicle crash. A chest tube was inserted to treat a simple pneumothorax and hemothorax. The
    chest drainage system has drained 400ml of light red fluid during the 1st 6 hours after
    insertion. The patient has become increasingly short of breath during the past hour. What
    physical assessment skills and strategies would you use to determine potential changes in the
    patient’s respiratory condition? What are potential causes of this increasing shortness of
    breath? What would you do to prepare for an emergency situation in this patient? (30pts)

    Assessing the airway patency and listen to the lungs. Observe breathing pattern, including use of
    accessory muscles. Monitor cardiac rhythm. Measure vital signs and pulse oximetry will help to
    determine the potential changes in the patient’s respiratory condition. Shortness of breath can result
    from a range of problems, including an allergic reaction, an anxiety attack, or anemia. But most often,
    the underlying cause is a heart or lung condition. During this kind of emergency situation, the best
    management for these patients includes early mobilization, aggressive pain control, proper fluid
    management, and respiratory physiotherapy. Endotracheal intubation should be reserved for the
    patients with airway compromise, refractory problems with gas exchange, hypoventilation, and
    decreased mental status.

    2. Consider the scenario and answer the following questions. Case Study: Community Acquired
    Pneumonia

    Teresa, a 20 year old college student, lives in a small dormitory with 30 other students. Four weeks
    after start of classes, she was diagnosed as having bacterial pneumonia and was admitted to the
    hospital. (20 pts., 5 pts. each)

     What intervention can the nurse provide to decrease the viscosity of secretions?

    Controlled coughing, this type of coughing comes from deep in your lungs. Postural drainage, the
    patient will lie down in different positions to help drain mucus from her lungs. Also mucolytic agents
    reduce sputum viscosity and improve secretion clearance.

     The nurse is assessing Teresa during the admission process. What manifestations of bacterial
    pneumonia does the nurse expect to find?
     When cough, it may produce greenish, yellow or even bloody mucus.
     Fever, sweating and shaking chills.
     Shortness of breath.
     Rapid, shallow breathing.
     Sharp or stabbing chest pain that gets worse when you breathe deeply or cough.
     Loss of appetite, low energy, and fatigue.

     The nurse assesses Teresa for arterial hypoxemia. What does the nurse understand is the
    reason why this complication develops?

    Bronchospasm causes alveolar collapse, which decreases the surface area necessary for perfusion;
    mucosal edema occludes the alveoli, thereby producing a drop in alveolar oxygen; venous blood is
    shunted from the right to the left side of the heart. The pathophysiological causes of arterial hypoxemia
    are low inspired partial pressure of oxygen (FiO2), alveolar hypoventilation, ventilation–perfusion (V/Q)
    mismatch, and veno-arterial (“right-to-left”) shunting of blood.

     The nurse is assessing vital signs and lung sounds every 4 hours. What complications should
    the nurse monitor for?
     Complaints of shortness of breath (dyspnea)
     Bluish or cyanotic appearance of the nail beds, lips, mucous membranes
     and skin
     Restlessness, irritability, confusion, decreased level of consciousness
     Pain during inspiration and expiration
     Labored or difficult breathing
     Orthopnea
     Use of accessory muscles
     Abnormal breath sounds such as wheezes, rhonchi or rales
     Inability to breathe spontaneously
     Thick, frothy, blood-tinged or copious sputum production
     Paradoxical chest wall movement

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