Oxygenation case study

CASE STUDY
George Burney, a 67-year-old Caucasian man diagnosed by a physician with emphesema 4 years ago, reports that he has had a fever and
has chest pain when he takes a deep breath or coughs. He presents to the free walk-in clinic today for an evaluation. The nurse interviews
Mr. Burney using specific probing questions. The client reports that he experiences chest pain when coughing and taking a deep breath.
He also reports development of fever. The nurse explores Mr. Burney’s health concerns using the OLDCARTS memonic. After exploring
Mr. Burney’s report of chest pain, cough, and fever, and long-term tobacco use, the nurse continues with the health history. Mr. Burney
reports a history of shortness of breath due to emphysema first diagnosed 4 years ago and an episode of pneumonia 2 years ago. Denies
having had any thoracic surgery. Mr. Burney’s medication history includes: Mucinex 600 mg every AM and Combivent, 2 puffs 4 times
daily. He denies medication, food, environmental, or insect allergies. Mr. Burney reports having had a chest x-ray 2 years ago that showed
pneumonia and emphysema. Receives influenza vaccine annually and has had one this year. Received pneumococcal vaccine 2 years ago
at age 65. Denies having had a TB skin test. Denies having had formal pulmonary function testing. Denies travel outside of the United
States.
Mr. Burney’s father, a smoker, suffered from emphysema and died due to lung cancer at age 67. His mother died at 74 years of age due to
congestive heart failure. Mr. Burney has two younger brothers who neither smoke nor have any significant health problems. His paternal
grandfather died in his 80s; the cause of death is unknown to client. His paternal grandmother died at age 85 due to “old age.” Mr.
Burney’s maternal grandfather died at age 65 due to stomach cancer and his maternal grandmother died at age 70 due to breast cancer.
Client exposed to second-hand smoke since birth. Denies any family history of asthma.
The nurse explores Mr. Burney’s nutritional history. His 24-hour diet recall consists of: Breakfast—four 8-ounce cups of coffee, two glazed
donuts; lunch—half of ham sandwich, 8-ounce cup of coffee; afternoon snack—chocolate chip cookies and cup of coffee; dinner—few
bites of meatloaf, mashed potatoes and gravy, cup of coffee.
Mr. Burney has smoked at least one pack of cigarettes per day since he was 16 years of age (51 pack years). He has tried unsuccessfully to
quit smoking a few times and states, “I like to smoke too much to quit.” He reports always smoking a cigarette upon getting out of bed,
after every meal, and when driving. He says that he smokes intermittently throughout the day. Denies exposure to environmental
inhalants. Mr. Burney is a retired supervisor in the auto industry and worked in an office. He lives with his wife, who is a nonsmoker. He is
usually able to perform ADLs with little or no difficulty. However, he reports that he has noticed having to “slow down to catch my breath”
when gardening or doing yard work recently. Denies any stressors at this time. He denies use of herbal medicines or alternative therapies
to manage respiratory problems.

3

Learning Activities

Assignment 1.1
Read through the above narrative and identify what information is relevant. Then, highlight the cues in the text
(Recognize Cues/Assessing).
Assignment 1.2
Subjective data related to thoracic and lung assessment provide many clues about underlying respiratory problems
and associated nursing diagnoses, and clues about the risk for the developing lung disorders. Information regarding
the client’s level of functioning is also crucial because some respiratory issues significantly impact a person’s ability
to perform activities of daily living (ADLs). When collecting subjective data, remember to follow up on the client’s
related signs and symptoms to determine specific respiratory problems.
As the fact-finding mission of the health history proceeds and data are collected, the nurse is putting pieces of the
patient’s puzzle together. By asking questions, the nurse clarifies the patient’s problems and teaching needs. Each
time the patient has a positive response to a question, the nurse must address the question further. As a new
nurse, the use of the mnemonic “OLD CART” is instrumental in assisting you to formulate questions.
• What questions would you ask Mr. Burney to identify the history of his present health concern? Using the
table on the attached concept map, formulate a list of questions to ask Mr. Burney. Additionally, include
your rationale for asking each question and support with evidence from the literature (your textbooks),
using appropriate APA format.
Assignment 1.3
• What does the information in the clinical narrative make you think? Based on the clinical narrative and the
questions you asked, what do you suspect is the patient’s problem? Consider acute and chronic medical
conditions. Create a list of possible impaired exemplars appropriate for this client on the attached concept
map (Analyzing Cues/Diagnosing).
Assignment 1.4
After reviewing Mr. Burney’s clinical narrative, analyze the data by asking yourself:
• What information is relevant to the patient’s situation? (Recognizing Cues/Assessing)
Identify and record the relevant subjective information on the attached concept map.
Assignment 2.1
You identify Mr. Burney has altered gas exchange and suspect ventilation impairment associated with chronic
bronchitis/emphysema. You must now perform a focused assessment of the lungs and thorax. On the attached
chart, identify:
• assessment procedures for a focused respiratory assessment;
• abnormal clinical manifestations you anticipate for the patient with COPD;
• rationale for the expected abnormal findings.

4

• What do you suspect is his respiratory rate and oxygenation saturation? Why?
Assignment 3.1
Discuss the factors (pathophysiology) that contribute to the medical diagnosis – COPD.
Assignment 4.1
After collecting subjective and objective data about the thorax and lung assessment, identify abnormal findings
and client strengths. (Analyzing Cues)
Using the attached concept map, cluster the data to reveal any significant patterns or abnormalities. These data
may then be used to make clinical judgments about the status of the client’s thorax and lungs.
Assignment 4.2
Now that you have created cue clusters draw inferences and make clinical judgments based on available
information. (Prioritize Hypothesis & Generate Solutions/Planning)
Using the attached concept map, identify:
• three (3) priority problems appropriate for the client with impaired gas exchange.
Assignment 4.3
Using the attached concept map, identify:
• three (3) expected outcomes, using SMART format.
o You should have one (1) expected outcome for each of the three priority problems identified in 4.2.

Assignment 4.4
Using the attached concept map, identify:
• two (2) nursing interventions and the rationale.