Case Study

Mr. L. Stevens, age 80, has been admitted to the medical unit in acute distress. His respirations are labored, and he is very lethargic. He has been a resident of the Long View skilled nursing facility (SNF) for the past 9 months. He had previously lived with his nephew until he became concerned that he could no longer be left alone while he was working. Mr. Steven's admitting diagnosis is right upper lobe (RUL) pneumonia. The transfer notes from the SNF indicate that he has had little or no appetite for the past 2 weeks. His fluid intake for the past few days has consisted of occasional sips of orange juice. The SNF also reports that Mr. Stevens has had difficulty swallowing his medications.

During the admission process, the nurse noticed that he is dyspneic and emaciated. Shortly after his admission to the unit, his nephew arrived and informed the nurse that Mr. Stevens had developed a chest cold about 2 weeks ago and that the cold seemed worse each time he visited him. He has been bedridden for most of the past week. The nephew stated that he knew he was sick when he refused to eat his favorite rice pudding that he made especially for him.

Past medical history is significant for mild congestive heart failure (CHF) for which he takes digoxin 0.125 mg qd and furosemide 20 mg qd. He also had a mild stroke about 2 years ago with some residual left sided weakness.Assessment of the respiratory system found crackles on the right side, a cough producing tenacious, green sputum, and +3 pitting ankle and sacral edema. Vital signs are T 100 F, P 92 and weak and thready, R 24 and shallow, BP 120/72. Physician's orders state to: start O₂ at 4L/NC (nasal cannula), IV of 1000 cc 5% D/W (Dextrose in Water) with KCl 20 mEq to infuse at 75 cc/hr. Intake and output (I&O). Obtain a sputum culture and sensitivity (C&S). Start cefotaxime sodium 1 g, IVPB (Intravenous Piggyback) q12h after sputum culture obtained. Continue digoxin 0.125 mg qd, give furosemide 40 mg bid, and begin asprin therapy of 81 mg daily. Also have blood drawn for serum K⁺, Na⁺, blood urea nitrogen (BUN), serum creatinine and blood glucose, complete blood count (CBC), and albumin level.

Today you are assigned to take care of Mr. Sevens. It was reported to you that he failed his swallow evaluation and a gastrostomy tube (PEG) was placed yesterday. Medications are now ordered to be given down his PEG tube. He was started an enteral tube feeding running at 75 ml/hr; with residual checks per protocol and to flush the tube with 100mL of water every 4 hours. The reporting nurse states that Mr. Stevens has had several loose stools during the night and has been complaining of abdominal fullness. She reports bowel sounds are hyperactive. His residuals during the night were 50 and 75. She reports `!q`that Mr. Stevens dyspnea is slightly improved, however he remains on a NC at 4L. There are still crackles in his lungs and he has 2+pitting edema. Sputum culture was obtained.

Problems/Nursing Concerns

Based on the data in the case study for Mr. Stevens, what problem/nursing concern do you wish to address first? Choose the three nursing concerns with the highest priority.

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Clinical Decisions

Choose three priority interventions with rationales for each nursing concern.

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Rationale:

Intervention:

Rationale:

Intervention:

Rationale: