HNN112 Lecture Notes - Lecture 11: Slot Machine, Vital Signs, Chronic Obstructive Pulmonary Disease
HNN112 WEEK 11 Seminar Note
Case study & example answer
Mr. Taylor, 54 years-old, was admitted yesterday afternoon with a history of chronic lung
disease (emphysema). His admission diagnosis is right lower lobe pneumonia. He has a
cough and his temperature at 0600 hours was high (38.7 Celsius degree). His skin is dry and
flushed. He also has very little energy.
Mr Taylor has commenced on antibiotics (orally), he is to be encouraged to drink 1500mls of
fluid per day and to ambulate at least every two hours.
The discharge plan for him is that he can go home when his temperature has resolved (likely
to be 2-3 days).
Folloig hadoer, ou go to Mr. Talor’s roo ad itrodue ourself. You otie that
when he coughs he braces his side, and any physical effort he makes results in increased
breathlessness.
You assist Mr. Taylor to sit out of bed for breakfast and later with his morning hygiene
needs. During these interactions Mr. Taylor tells you that he has been living by himself since
his wife died 2 years ago. He tells you that most of his time is spent fishing by himself or
plaig the pokies ith ates at the loal R“L. He also states I’ sik of eig told hat to
do ou dotors ad urses.
You take his vital signs at 1000 hours: Temperature 38.5 Celsius degree (febrile), Pulse 88
(normal rate and regular), Respirations 26 (shallow and fast) and Blood Pressure 136/82
(within normal limits).
When spending time with him taking his vital signs he jokes about the fact that his mate
Jake found him on the day of his admission. Jake found him still in bed - confused, rambling
and restless. Jake called the ambulance and came with him to the hospital. Apparently Jake
had goe to Mr Talor’s house because he had not been at the pokies for three days – Mr
Talor jokes agai statig that I thought it as just the flu, aa, o-one would miss me
if I et.
Nursing Process
(Assessment – Problem Identification – Planning – Implementing – Evaluation)
1.
From the scenario identify relevant data/cues including patient
symptoms to assist your assessment of Mr. Taylor;
Patient identity
Mr. Taylor, 54 years-old, male
Past medical history
chronic lung disease(emphysema), right
lower lobe pneumonia
symptoms
Cough, 38.7 cd tempt, very little energy,
when he coughs he braces his side, any
physical effort he makes results in
increased breathlessness, his skin is dry
and flushed
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Document Summary
Mr. taylor, 54 years-old, was admitted yesterday afternoon with a history of chronic lung disease (emphysema). His admission diagnosis is right lower lobe pneumonia. He has a cough and his temperature at 0600 hours was high (38. 7 celsius degree). Mr taylor has commenced on antibiotics (orally), he is to be encouraged to drink 1500mls of fluid per day and to ambulate at least every two hours. The discharge plan for him is that he can go home when his temperature has resolved (likely to be 2-3 days). Follo(cid:449)i(cid:374)g ha(cid:374)do(cid:448)er, (cid:455)ou go to mr. ta(cid:455)lor"s roo(cid:373) a(cid:374)d i(cid:374)trodu(cid:272)e (cid:455)ourself. You (cid:374)oti(cid:272)e that when he coughs he braces his side, and any physical effort he makes results in increased breathlessness. You assist mr. taylor to sit out of bed for breakfast and later with his morning hygiene needs. During these interactions mr. taylor tells you that he has been living by himself since his wife died 2 years ago.
