NRS 455 RS T1 Case Study

NRS 455 RS T1 Case Study

Case Study: Mrs. R.
Directions: Read the case study below. Evaluate the information and formulate a
conclusion based on your evaluation. Complete the critical thinking table and submit this
completed template to the assignment dropbox.
Case Study: Mrs. R.
It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the
pathophysiological processes of disease, the clinical manifestations and treatment protocols, and
how they affect clients across the life span.
Evaluate the Health History and Medical Information for Mrs. R., presented below.
Health History and Medical Information
Mrs. R. is a 68-year-old married woman who has a history of hypertension, chronic heart failure,
and chronic obstructive pulmonary disease (COPD). Despite requiring 2L of oxygen/nasal
cannula at home during activity, she continues to smoke two packs of cigarettes a day and has
done so for 40 years. Three days ago, she had sudden onset of flu-like symptoms, including
fever, productive cough, nausea, and malaise. Over the past 3 days, she has been unable to
perform ADLs and has required assistance in walking short distances. She has not taken her
antihypertensive medications or medications to control her heart failure for 3 days. Today, she
has been admitted to the hospital ICU with acute decompensated heart failure and acute
exacerbation of COPD.
Subjective Data
1. Is very anxious and asks whether she is going to die.
2. Denies pain but says she feels like she cannot get enough air.
3. Says her heart feels like it is "running away."
4. Reports that she is exhausted and cannot eat or drink by herself.
Objective Data
5. Height 175 cm; Weight 95.5kg.
6. Vital signs: T 37.6C, HR 118 and irregular, RR 34, BP 90/58.
7. Cardiovascular: Distant S1, S2, S3 present; PMI at sixth ICS and faint: all peripheral
pulses are 1+; bilateral jugular vein distention; initial cardiac monitoring indicates a
ventricular rate of 132 and atrial fibrillation.
8. Respiratory: Pulmonary crackles; decreased breath sounds right lower lobe; coughing
frothy blood-tinged sputum; SpO2 82%.
9. Gastrointestinal: BS present: hepatomegaly 4cm below costal margin.