ClinicalCaseStudy Final Essay

Submitted By Fonda76
Words: 6367
Pages: 26

Clinical Case Study
Fonda Robinson
College of Southern Nevada
Nurse 211
LuAnn Gallacher MSN, RN
October 08, 2013
Clinical Case Study
The purpose of this clinical case study is to take an educational look and provide information based on facts and research. This paper will discuss the clinical presentation of RE a Filipino gentleman who was admitted to Mountainview hospital with potential sepsis and Idiopathic Pulmonary Arterial Hypertension. It will explore RE’s medical history and presentation upon admission. Also explored will be his abnormal labs, diagnostic test, medications, and the pathophysiology of Idiopathic Pulmonary Arterial Hypertension and ruling out sepsis. The patient’s clinical presentation will be compared with that of nursing literature. Finally there will be discussion of the plans of care utilized during the clinical day. It was found that RE’s clinical presentation upon admission for possible sepsis was mostly related to his history and treatment of Idiopathic Pulmonary Hypertension. Although, he did have a clinical bacterial infection cause by improper care of his central venous access device.
RE is a forty-eight year old male, who presented to the Emergency Department at Mountainview Hospital with complaints of fever and body aches for the past one day. He reported having a fever of 101.0 degrees Fahrenheit, some nausea, vomiting, and abdominal pain. He reported having a dry cough. He stated he had diffuse pain that was not localized to any one area. RE denied having any chest pain. He reported having shortness of breath that occurs with light activity. RE has a Veletri infusion which was increased by his pulmonologist approximately one week prior.
RE’s physical exam upon admission showed, vital signs of a heart rate (HR) of 79, blood pressure (BP) of 114/76, respirations (RR) of 27, oxygen saturation (O2 sat) of 99 percent, temperature (T) of 98.4 degrees Fahrenheit (F). He was awake and alert, appeared to be in moderate distress, and stated that he was very thirsty. RE denied having any headache or vision changes. Cranial nerves II through XII were grossly intact. He was noted to have some jugular venous distention (JVD), was slightly tachycardic, and had no murmurs, rubs, or gallops. His lungs were clear to auscultation. His abdomen was soft, with tenderness and fullness in the epigastrium, and upper right quadrant. Bowel sounds were present. RE denied having any dysuria, urgency, or frequency. RE had no edema or calf tenderness in extremities. He denied any partial weakness or numbness.
RE’s co-morbidities include Idiopathic Pulmonary Arterial Hypertension (IPAH), Second Degree Heart Block Type 1, Hypertension (HTN), and Chronic Respiratory Failure (CRF). His past surgical history includes a Cholecystectomy on December 22, 2013 and a Hernia repair with no dates available. RE’s home medications include Potassium Chloride, Lasix 40 milligrams every day, and Veletri infusion.
General Survey
RE was lying in bed with a hospital gown on, and the bed covers were not covering him. He was cooperative, pleasant, and talkative. His speech was clear and content was appropriate to content being discussed. He was exhibiting signs of restlessness by constant movement in bed. Infusing was Dextrose 5% 0.45 Normal Saline (NS) at a rate of 100 milliliters (ml) per hour, and Potassium Chloride at a rate of 100 ml per hour.
Vital signs
RE had an oral temperature of 98 degrees Fahrenheit. His heart rate was 112 beats per minute (bpm). His blood pressure was 111/78. His respiratory rate was 30 and slightly labored. His chest was symmetrical. His Pulse Oximetry was 98 percent on three liters (l) of oxygen per minute with a nasal cannula.
Pain Assessment
RE stated that his pain level was a five out of ten. He described his pain as an all over, numbing, joint pain that was constant. He stated that medication makes the pain better.