Case study.pdf

I. Introduction This case study aims to: Define ARDS Determine the Patient’s Profile Examine the signs, symptoms, lab results and other health issues Elaborate the pathophysiology of the disease Provide the proper nursing interventions by creating a nursing care plan....

I. Introduction This case study aims to: Define ARDS Determine the Patient’s Profile Examine the signs, symptoms, lab results and other health issues Elaborate the pathophysiology of the disease Provide the proper nursing interventions by creating a nursing care plan. II. Case Description Mr. Garcia, a 55-year-old male, presented with a week-long history of feeling unwell, fever, persistent dry cough, and shortness of breath. Despite being initially diagnosed with a respiratory infection, his condition worsened rapidly, leading to dyspnea, cyanosis, hypoxia, and confusion over the last 24 hours. He denied recent travel but had contact with a coworker who had pneumonia. Mr. Garcia was diagnosed with Acute Respiratory Distress Syndrome (ARDS) after being admitted again to the emergency department. III. Patient Profile Name: Mr. Garcia Age: 55 years old Gender: Male Occupation: Construction Worker Chief Complaint: Severe difficulty breathing or dyspnea with rapid onset in the last 24 hours, combined with chest tightness and fatigue. IV. Health Assessment and History Upon assessing the patient, here are the retrieved data: General Appearance: The patient is in obvious respiratory distress, using accessory muscles to breathe. Vital Signs: Temperature: 39°C (102.2°F) Heart rate: 125 beats per minute (tachycardic) Respiratory rate: 32 breaths per minute (tachypneic) Blood pressure: 88/60 mmHg (hypotensive) Oxygen saturation: 78% on room air Respiratory examination: Bilateral crackles on lung auscultation, diminished breath sounds at the lung bases, and no wheezing. Cardiovascular examination: Tachycardia with no murmurs or gallops. Neurological examination: The patient is lethargic but responsive to verbal stimuli. Medical History: Hypertension, Type 2 Diabetes Mellitus (10 years), Smoking history of 20 years (1 pack a day), no known allergies. V. Laboratory test and Results INVESTIGATIONS RESULTS NORMAL FiO2 0.5 0.21 pH 7.30 7.35 PaO2 55 mmHg 75-100 mmHg PaCO2 48 mmHg 35-45 mmHg HCO3 22 mEq/L 22-26 mEq/L O2 saturation (SpO2) 78% > 94% WBC 14,000/mm3 4,500-11,000/mm3 Hb 12.5 g/dL 13.5-17.5 g/dL HCT 37% 40-54% Platelets 130,000/mm3 150,000-400,000/mm3 Sodium 138 mEq/L 135-145 mEq/L Potassium 4.8 mEq/L 3.5-5.0 mEq/L Chloride 98 mEq/L 98-106 mEq/L Bicarbonate 22 mEq/L 22-26 mEq/L AST 65 U/L 10-40 U/L ALT 70 U/L 7-56 U/L Biliburin 1.5 mg/dL 0.1-1.2 mg/dL Creatinine 1.4 mg/dL 0.7-1.3 mg/dL Blood Urea Nitrogen 32 mg/dL 7-20 mg/dL C-reactive Protein 150 mg/L