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NUR 2032C Respiratory Distress Lab Report
- Course
- NUR 2032C
- Institution
- Keiser University
This is a comprehensive and detailed lab report on; Respiratory Distress for NUR 2032C. *Essential!!
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Respiratory DistressClinical Reasoning Activity
Mark Peterson, 45 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
Gas Exchange
Infection
Clinical Judgment
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
Management of Care 17-23%
Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity
Basic Care and Comfort 6-12%
Pharmacological and Parenteral Therapies 12-18%
Reduction of Risk Potential 9-15%
Physiological Adaptation 11-17%
© 2019 Keith Rischer/www.KeithRN.com
, Part I: Present Problem:
Mark Peterson is a 45-year-old African American male with a new diagnosis of cardiomyopathy (40% EF), poorly
controlled type one diabetes mellitus, hypertension, and stage III chronic kidney disease. He is a one-pack-per-day smoker
who came to the emergency department (ED) with increased redness in his lower extremities, fever, and chills. He was
diagnosed with cellulitis and acute renal failure. He received his first dose of ceftriaxone 1 g IVPB in the ED. He has a
baseline creatinine of 2.8, and his current creatinine is 3.9. His WBC is 18.5. He was just admitted to the med/surg unit
where you will be the primary nurse caring for him. His initial set of VS: T: 99.8 F/37.7 C (o) P: 84 reg R: 22 (reg) BP:
148/88 O2 sat: 93% room air. He has fine bibasilar crackles in both bases posteriorly that do not clear with a cough.
Respirations do not appear to be labored, and he denies shortness of breath.
1. What clinical data do you notice that is RELEVANT and why is it clinically significant?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT Data: Clinical Significance:
One-pack-per-day smoker -Smoking can lead to more problems associated with his hypertension and
other medical diagnosis
WBC high (18.5) -This is very high can be a sign of an infection/illness
R:22 -patient is above normal levels of respiratory (may not be at risk) but should
be addressed
Temp: 99.8F/37.7 (C) -Has a high temp may be because of the elevated WBC, that can be an
indication of an infection
Four Hours Later…
It has been four hours since he was admitted. You notice that his O2 sat on room air has decreased from 95 percent to 88
percent, his respiratory rate has increased from 22 to 28 at rest, and he has coarse crackles halfway up bilaterally
posteriorly. You have a PRN order to titrate oxygen to keep O2 sat >92%, so you place a nasal cannula at 2 L/min which
improves his O2 sat to 94%. Two hours later, his respiratory rate has increased to 24, and his O2 sat is 90 percent. He now
requires 4 L/min per nasal cannula to keep his O2 sat greater than 92%.
His current VS are T: 99.6 F/37.6 C (o) P: 94 R: 28 BP: 156/90 O2 sat: 92% on 6 L/min per n/c. You contact the
primary care provider because of his increasing oxygen needs. He is feeling more short of breath. He has had 400 mL of
water but has not been able to void since admission to the floor. His bladder ultrasound (BUS) reveals 90 mL of urine in
his bladder.
1. What clinical data do you notice that is RELEVANT and why is it clinically significant?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT Data: Clinical Significance:
O2 sat on room air has decreased from 95% -patient is becoming hypoxemic
to 88%
RR increased from 22 to 28 -can be from his need for oxygen because his O2 stats are dropping
significantly
He has coarse crackles halfway up -From excessive fluid in the lungs, which is an indication of pulmonary edema
bilaterally posteriorly.
He has had 400 mL of water but has -may be because of his underlying issues with renal failure, pt is unable to
not been able to void since admission pass urine because of a blockage
to the floor. His bladder ultrasound
(BUS) reveals 90 mL of urine in his
bladder.
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