Congratulations to everyone for making it to N4. Here is the Respiratory Case studies for the N4 Review on March 28th, L118. Please bring them.

Chapter 26: NURSING MANAGEMENT: Upper Respiratory Problems
Cancer of the Larynx

Patient Profile
Mr. Carlson, a 60-year-old white man, was admitted for evaluation of mild pain on swallowing and a persistent sore throat over the past year.

Subjective Data
· States that his symptoms worsened in the last 2 months
· Has used various cold remedies to relieve symptoms without relief
· Has lost weight because of decrease in appetite and difficulty swallowing
· Has smoked 3 packs of cigarettes a day for 40 years
· Consumes 6 cans of beer a day

Objective Data
Laryngoscopy
· Subglottic mass

Physical Examination
· Enlarged cervical nodes

Computed Tomography Scan
· Subglottic lesion with lymph node involvement

Collaborative Care
· Total laryngectomy with tracheostomy with inflated cuff
· Nasogastric tube

Critical Thinking Questions
1. What information in the assessment suggests that Mr. Carlson might be at risk for cancer of the larynx?
2. What diagnostic tests are typically performed to evaluate the extent of this problem?
3. What teaching should the nurse plan for Mr. Carlson before and after laryngectomy?
4. Discuss methods used to restore speech after laryngectomy.
5. What teaching is required to assist this patient to assume self-care after his surgery? What precautions should the patient take because of his stoma?
6. Based on the assessment data presented, write one or more nursing diagnoses. Are there any collaborative problems?

Chapter 27: NURSING MANAGEMENT: Lower Respiratory Problems
Aspiration Pneumonia

Patient Profile
Sam, a 27‑year‑old African-American male, was admitted to the hospital because of an uncontrollable fever. He was transferred from a long-term care facility. He has a history of a gunshot wound to his left chest. Following a cardiac arrest after the accident he developed hypoxic encephalopathy. He has a tracheostomy and gastrostomy tube. He has a history of methicillin-resistant Staphylococcus aureus (MRSA) in his sputum.

Subjective Data
· Family says that they visit him regularly and are very devoted to him.

Objective Data
Physical Examination
· Thin, cachectic African American man in moderate respiratory distress
· Unresponsive to voice, touch, or painful stimuli
· Vital signs: temperature 104° F (40° C), heart rate 120, respiratory rate 30, O2 saturation 90%
· Chest auscultation revealed crackles and scattered rhonchi in the left upper lobe

Diagnostic Studies
· Serum albumin 2.8 g/dl (28 g/L)
· White blood cell (WBC) count 18,000/ml (18 x 109/L)
· Sputum specimen: thick, green colored, foul smelling; cultures pending
· Arterial blood gases: pH 7.29, PaO2 80 mm Hg, PaCO2 40 mm Hg, bicarbonate 16 mEq/L
· Stool culture positive for Clostridium difficile
· Chest x‑ray: infiltrate in left upper lobe; no pleural effusions noted

Critical Thinking Questions
1. What types of infectious disease precautions should be taken related to Sam’s hospitalization?
2. What clinical manifestations of aspiration pneumonia did Sam exhibit? Explain their pathophysiologic bases.
3. What antibiotic medication is likely to be prescribed?
4. What is his oxygenation status and metabolic state?
5. What other clinical issues need to be addressed in his plan of care?
6. What family interventions would you initiate?
7. Based on the assessment data presented, write one or more appropriate nursing diagnoses. Are there any collaborative problems?

Chapter 28: NURSING MANAGEMENT: Obstructive Pulmonary Diseases
Asthma

Patient Profile
Mrs. S., a 30-year-old African American mother of two preschoolers, comes to the emergency department (ED) with severe wheezing, dyspnea, and anxiety. She was in the ED only 6 hours ago with an acute asthma attack.

Subjective Data
· Treated in the ED previously with nebulized albuterol and responded quickly
· Can speak only one- to three-word sentences
· Is allergic to cigarette smoke
· Began to experience increased shortness of breath and tightness in her chest when she returned home
· Used albuterol MDI (without a spacer) repeatedly at home with no relief

Objective Data
Physical Examination
· Uses accessory muscles to breathe
· Has audible wheezing
· Respiratory rate 34/min
· Auscultation reveals no air movement in lower lobes
· Heart rate 126 beats/min

Diagnostic Studies
· ABGs: PaO2 80 mm Hg, Paco2 35 mm Hg, pH 7.46
· PEFR: 150 L/min (personal best: 400 L/min)

Critical Thinking Questions
1. Why did Mrs. S. return to the ED? Explain the pathophysiology of this exacerbation of asthma.
2. What are the nursing care priorities for Mrs. S.?
3. What are the complications the nurse must be ready for based on her assessment of Mrs. S.?
4. What should be included in her discharge plan of care?
5. Based on the assessment data presented, write one or more nursing diagnoses. Are there any collaborative problems?