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Case #4 Jim Lawson (adapted from Unfolding Case Studies, 2001)

Day 1, 1330: Jim Lawson is a 64yo WM admitted to the hospital medical floor for a severe
respiratory infection. Jim, a 2ppd smoker, has a hx of COPD. He woke this AM with increased
SOB and prod. cough of copious amounts of green-brown sputum. VS B/P 144/88, P 94, R 30,
T 100.2 O. Orders include: STAT ABG,sputum for C&S, and CXR. Tx: After diagnostics, begin
Ampicillin 500 mg IV q6h, IV D5W 100cc/h, Albuterol nebs qid and prn acute dyspnea, and O2
1.3L via n/c.

1. What VS result concerns you the most? Why?
The Temperature is elevated. The BP is high as well. These vital signs are
concerning because they indicate that there could be an infection.
2. What else might you like to know about the client before you begin to care for
Does he have asthma? What meds has he taken?
3. Why is each diagnostic performed? And why is it important not to begin the tx
until after them?
Each diagnostic is performed to see what is wrong with the patient. It is important
because you don't want to treat him for something he doesn't have.
4. What is the benefit of IVFs for the patient?
Since he can't breath, it probably isnt a good idea to put medication and fluids directly
down his throat.

Day 1, 2300: Jim puts on his call light in an acute episode of dyspnea. He is breathing rapidly
and shallowly at 40 bpm. His color is dusky w/ circumoral cyanosis. He is frightened and
diaphoretic, lying on his side as he calls for help.

1. What actions do you take?
Put him on O2, give medications, and change the position of the bed.
Day 1, 2330: Jim verbalizes a little relief from a change of position and a stat Albuterol
nebulizer tx. You continue to monitor him closely.

1. Explain how the Albuterol nebulizer assisted Jim.
Albuterol is a corticosteroid and they help unconstrict the bronchi so the patient can
Day 2, 0100: Once again, Jims condition begins to deteriorate. His latest ABG results suggest
he needs to be intubated and placed on a mechanical ventilator. Jim is transferred to ICU.

1. Explain the use of mechanical ventilation in severe respiratory distress.
Mechanical Ventilation helps the patient breathe. The machine relieves the lungs so that
they can heal and not work as hard.
Day 7, 1000: Jim was extubated 2 days ago. He is breathing on his own and his vital signs
have returned to normal. He will be prescribed O2 PRN for home use and albuterol inhaler for
use PRN.
1. Teach Jim how to use the inhaler. Write down the instructions for him.
Take off the cap and shake the inhaler hard
Breathe out all the way
Hold the inhaler 1 - 2 inches in front of your mouth
Start breathing in slowly through your mouth, and then press down on the inhaler
1 time. (If you use a spacer, press down on the inhaler before you breathe in.
Within 5 seconds, begin to breathe in slowly.)
Keep breathing in slowly, as deeply as you can.
Hold your breath as you count to 10 slowly, if you can. This lets the medicine
reach deep into your lungs.
2. What precautions should Jim take with the O2 at home?
Keep it away from flames. DONT SMOKE.
3. What recommendations do you have for Jim to avoid further hospitalizations?
Quit Smoking, and use the Inhaler