This document provides a case study about a 68-year-old man, D.Z., admitted to the hospital for an acute exacerbation of chronic obstructive pulmonary disease (COPD). He has a history of hypertension, diabetes, pneumonia, and smoking. His vital signs and oxygen saturation are abnormal on admission. The case study describes his physician's orders, medications, and initial nursing assessments and interventions.

1. Case Study
COPD Exacerbation
Difficulty: Advanced
Setting: Hospital
Index Words: chronic obstructive pulmonary disease (COPD),
medications, nutrition, patient education, assessment, coping
Giddens Concepts: Clinical Judgment, Collaboration, Gas
Exchange, Nutrition, Oxygenation, Safety
HESI Concepts: Assessment, Clinical Decision Making—
Clinical Judgment, Collaboration/Managing Care, Gas
Exchange, Nursing Interventions, Nutrition, Oxygenation,
Safety
D.Z., a 68-year-old man, is admitted at 1600 to a medical floor
with a diagnosis of acute exacerbation of chronic obstructive
pulmonary disease (COPD). His other past medical history
includes hypertension and type 2 diabetes. He has had
pneumonia yearly for the past 3 years and has been a two-pack-
a-day smoker for 38 years. His current medications include
enalapril (Vasotec), hydrochlorothiazide (HCTZ), metformin

2. (Glucophage), and fluticasone/salmeterol (Advair). He appears a
cachectic man who is experiencing dif- ficulty breathing at rest.
D.Z. seems irritable and anxious; he complains of sleeping
poorly and states that lately he feels tired most of the time. He
reports cough productive of thick yellow-green sputum. You
aus- cultate decreased breath sounds, expiratory wheezes, and
coarse crackles in both lower lobes anteriorly and posteriorly.
His vital signs (VS) are 162/84, 124, 36, 102° F (38.9° C), and
Spo2 88%.
·
Scenario
Physician's Orders
Diet as tolerated
Out of bed with assistance
2
IV of D5W at 50 mL/hr ECG monitoring
Oxygen (O ) to maintain Spo of 90%
2
Arterial blood gases (ABGs) in am
CBC with differential now
Basic metabolic panel (BMP) now Chest x-ray (CXR) daily
Sputum culture
Albuterol 2.5 mg plus ipratropium 250 mcg nebulizer treatment
STAT
Chart View
1. Are D.Z.'s VS and Spo2 acceptable? If not, explain why.

3. 2. Describe a plan for implementing these physician's orders.
3. What is the primary nursing goal at this time?
4. Based on this priority, identify three independent nursing
actions you would implement.
5. Identify three expected outcomes for D.Z. as a result of your
interventions.
Chart View
Medication Administration Record
Methylprednisolone (Solu-Medrol) 125 mg IVP every 8 hours
mcg 2 puffs twice daily
Heparin 4000 units subcut every 12 hours Enalapril (Vasotec)

4. 10 mg PO daily
Albuterol 2.5 mg/ipratropium 250 mcg nebulizer treatment
every 6 hours Metformin (Glucophage) 500 mg PO twice daily
6. Indicate the expected outcome for D.Z. that is associated with
each medication he is receiving.
0.2
0.4
0.6
0.8
1
mL
7. Because D.Z. is on azithromycin (Zithromax), what
interventions need to be included in his plan of care? Select all
that apply.
a. Monitor intravenous (IV) site for inflammation or
extravasation.
b. Assess liver function study results and bilirubin levels.
c. Request a hearing test before initiating therapy.
d. Carefully dilute the medication in the proper amount of
solution.
e. Place D.Z. on intake and output.
f. Administer the medication over 30 minutes.
8. D.Z is ordered heparin 4000 units subcutaneous q12h. The
following vial is available. How many milliliters will D.Z.
receive? Shade in the dose on the tuberculin syringe.

5. 9. What are two common side effects of bronchodilators that
you need to assess for?
10. You deliver D.Z.'s dietary tray, and he comments on how
hungry he is. As you leave the room, he is rapidly consuming
the mashed potatoes. When you pick up the tray, you notice that
he has not touched anything else. When you question him, he
states, “I don't understand it. I can be so hungry, but when I
start to eat, I have trouble breathing and I have to stop.” One
theory for the increased work of breathing is based on
carbohydrate (CHO) loading. Explain this phenomenon.
11. Identify four interventions that might improve his caloric
intake.
12. You notice a box of dark chocolate on D.Z.'s overbed table.
He tells you that his wife brought him those because he always
wakes at night and eats four or five pieces. What is thought to
be the basis for this craving for chocolate?
13. After speaking with D.Z. about his diet and reviewing his
medications, you are now concerned about his glycemic control.
Hospital policy allows you to obtain as-needed blood glucose
levels for diabetic patients, so you direct the nursing assistive
personnel (NAP) to obtain D.Z.'s blood glucose level at 2100.

6. What is your responsibility in delegating this task to the NAP?
14. The NAP reports that D.Z.'s blood glucose level is 366
mg/dL. What action do you need to take and why?
2 Respiratory Disorders
15. What other health care professional would probably be
involved in D.Z.'s treatments and how?
Case Study Progress
The next morning, D.Z. is sitting in the bedside chair and
appears to be experiencing less difficulty breathing. He states
his cough remains productive of yellow-green sputum, although
it is “easier to cough up” than it was the previous day. You
auscultate decreased breath sounds and a few coarse crackles in
both lower lobes posteriorly. His VS are 150/78, 94, 24, 99.7° F
(37.6° C). His Spo2 is 92% with oxygen on at 2 L per nasal
cannula.
Arterial Blood Gases (ABGs)
pH
Paco
2
Hco
3
Pao

7. 2
Sao
2
7.34
58 mm Hg
32 mmol/L
65 mm Hg
92%
Chart View
16. Interpret D.Z.'s ABG values.
17. Has D.Z.'s status improved or not? Defend your response.
18. What interventions would you include in your plan of care
for D.Z. today?

8. Case Study Progress
D.Z.'s wife approaches you in the hallway and says, “I don't
know what to do. My husband used to be so active before he
retired 6 months ago. Since then he's lost 35 pounds. He is
afraid to take a bath, and it takes him hours to dress—that's if
he gets dressed at all. He has gone downhill so fast that it scares
me. He's afraid to do anything for himself. He wants me in the
room with him all the time, but if I try to talk with him, he
snarls and does things to irritate me. I have to keep working.
His medical bills are draining all of our savings, and I have to
be able to support myself when he's gone. Sometimes I go to
work just to get away from the house and his constant demands.
He calls me several times a day asking me to come home, but I
can't go home. You may not think I'm much of a wife, but quite
honestly, I don't want to come home anymore. I just don't know
what to do."
19. How would you respond to her statement?
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Case Study
Coronary Artery Disease and Pacemakers
Difficulty: Intermediate

9. Setting: Hospital, outpatient cardiac rehabilitation
Index Words: coronary artery disease (CAD), hypertension
(HTN), angina, lifestyle modification, medications, laboratory
values, assessment, risk factors, pacemaker, ECG strip, atrial
fibrillation, graded exercise (stress) test
Giddens Concepts: Caregiving, Perfusion, Patient Education
HESI Concepts: Assessment, Caregiving, Perfusion, Patient
Education
It is midmorning on the cardiac unit where you work, and you
are getting a new patient. G.P. is a 60-year- old retired
businessman who is married and has three grown children. As
you take his health history, he tells you that he began feeling
changes in his chest about 10 days ago. He has hypertension
(HTN) and a 5-year history of angina pectoris. During the past
week, he has had frequent episodes of mid-chest discomfort.
The chest pain responds to nitroglycerin (NTG), which he has
taken sublingually about 8 to 10 times over the past week.
During the week, he has also experienced increased fatigue. He
states, “I just feel crappy all the time.” A cardiac
catheterization done several years ago revealed 50% stenosis of
the right coronary artery (RCA) and 50% stenosis of the left
anterior descending (LAD) coronary artery. He tells you that
both his mother and his father had coronary artery disease
(CAD). He is currently taking amlodipine (Norvasc), metoprolol
(Lopressor), atorvastatin (Lipitor), and aspirin 81 mg/day.
·

10. Scenario
1. What other information are you going to obtain about his
episodes of chest pain?
2. What are common sites for radiation of ischemic cardiac
pain?
3. You know that G.P. has atherosclerosis of the coronary
arteries. You need to know his risk factors for CAD to plan
teaching for lifestyle modifications. What will you ask him
about?

11. 4. Although he has been taking sublingual nitroglycerin (SL
NTG) for a long time, you want to be certain he is using it
correctly. Which actions are correct when taking SL NTG for
chest pain? (Select all that apply.)
a. Stop the activity and lie or sit down.
b. Call 911 immediately.
c. Call 911 if the pain is not relieved after taking one SL tablet.
d. Call 911 if the pain is not relieved after taking three SL
tablets, 5 minutes apart.
e. Chew the tablet slowly then swallow.
f. Place the NTG tablet under the tongue.
5. You review the use and storage of SL NTG with G.P. Which
statement by G.P. indicates a need for further education?
Explain your answer.
a. “I will discard any open bottle of nitroglycerin after a year.”
b. “I will not store other pills in the nitroglycerin bottle.”
c. “I carry the tablets with me at all times.”
d. “I will keep the pills in their original brown bottle.”
CASE STUDY PROGRESS
When you first admit G.P., you place him on telemetry and
observe his cardiac rhythm.
6. Identify the rhythm:

12. 1 Cardiovascular Disorders
7. Explain the primary complication that could occur if this
heart rhythm were not treated.
8. Review G.P.'s history. What conditions may have contributed
to the development of this dysrhythmia?
9. You review G.P.'s laboratory test results and note that all of
them are within normal range, including troponin and creatinine
phosphokinase (CPK) levels. His potassium level is 4.7 mEq/L.
Given this and his current dysrhythmia, what is the likely cause
of the symptoms he has been experiencing this past week?

13. CASE STUDY PROGRESS
Within the hour, G.P. converts with intravenous diltiazem
(Cardizem) to sick sinus syndrome with long sinus pauses that
cause lightheadedness and hypotension.
10. What risks does the new rhythm pose for G.P.? Explain the
reasons for your answers.
CASE STUDY PROGRESS
Because G.P.'s dysrhythmia is causing unacceptable symptoms,
he is taken to surgery and a permanent DDDR pacemaker is
placed and set at a rate of 70 beats/min.
11. What does the code
DDDR mean?

14. 12. The pacemaker insertion surgery places G.P. at risk for
several serious complications. List three potential problems that
you will monitor for as you care for him.
13. G.P. will need some education regarding his new
pacemaker. What information will you give him before he
leaves the hospital?
14. G.P.'s wife approaches you and anxiously inquires, “My
neighbor saw this science fiction movie about this guy who got
a pacemaker and then he couldn't die. Is that for real?” How are
you going to respond to her?
15. G.P. and his wife tell you they have heard that people with
pacemakers can have their hearts stop because of microwave
ovens and cell phones. Where can you help them find more
information?
CASE STUDY PROGRESS
After discharge, G.P. is referred to a cardiac rehabilitation
center to start an exercise program. He will be exercise tested,
and an individualized exercise prescription will be developed
for him, based on the results of the exercise test.

15. 16. What information will be obtained from a graded exercise
(stress) test, and what is included in an exercise prescription?
1 Cardiovascular Disorders