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Pneumonia/Chronic Obstructive Pulmonary Disease Clinical Reasoning Case Study

Airway/Breathing (Oxygenation) Pneumonia/Chronic Obstructive Pulmonary Disease Clinical Reasoning Case Study

JoAnn Walker, 84 years old

Overview

This case study incorporates a common presentation seen by the nurse in clinical practice: community acquired pneumonia with a history of COPD causing an acute exacerbation. Principles of spiritual care are also naturally situated in

this scenario to provide rich discussion of “how to” practically incorporate this into the nurse’s practice.

Concepts (in order of emphasis)

  1. I. Gas Exchange
  2. II. Infection

III. Acid-Base Balance

  1. IV. Thermoregulation V. Clinical Judgment VI. Pain

VII. Patient Education

VIII. Communication

  1. IX. Collaboration
  1. Data Collection

History of Present Problem:

Pneumonia-COPD

JoAnn Walker is an 84-year-old female who has had a productive cough of green phlegm 4 days ago that continues to persist. She was started 3 days ago on prednisone 60 mg po daily and azithromycin (Zithromax) 250 mg po x5 days by her

clinic physician. Though she has had intermittent chills, she first noticed a fever last night of 102.0. She has had more

difficulty breathing during the night and has been using her albuterol inhaler every 1-2 hours with no improvement. Therefore she called 9-1-1 and arrives at the emergency department (ED) by emergency medical services (EMS) where

you are the nurse who will be responsible for her care.

Personal/Social History:

JoAnn was widowed 6 months ago after 64 years of marriage and resides in assisted living. She is a retired elementary

school teacher. She called her pastor and he has now arrived and came back with the patient. The nurse walked in the room when the pastor asked Joan if she would like to pray. The patient said, “Yes, this may the beginning of the end for me.”

What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse?

RELEVANT Data from Present Problem:

Clinical Significance:

Green phlegm

Chills

Fever (102.0)

Difficulty Breathing (no improvement with albuterol)

 These vital signs clinically show signs of infection. With the difficulty breathing I would think about possible respiratory infection

RELEVANT Data from Social History:

Clinical Significance:

84 years old

Live in assisted living facility

Religious preference

Her social history is clinically significant because with her age and being in close quarters with quite a few people could increase her risk for the spread of infection. Also we need to keep in mind her religious preference during her stay.

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?

(Which medication treats which condition? Draw lines to connect)

PMH:

Home Meds:

Pharm. Classification:

Expected Outcome:

·COPD/asthma

·Hypertension

·Hyperlipidemia

·Cor-pulmonale

· Anxiety disorder

· 1ppd smoker x40 years. Quit 10 years ago

1. Fluticasone/salmeterol

(Advair) diskus 1 puff every

12 hours

2. Albuterol (Ventolin) MDI

2 puffs every 4 hours prn

3. Lisinopril (Prinivil) 10 mg po daily

4. Gemfribrozil (Lopid) 600

mg po bid

5. Diazepam (Valium) 2.5 mg po every 6 hours as

needed

6. Triamterene-HCTZ (Dyazide) 1 tab daily

1. corticosteroid, beta 2 adrenergic agonist

2. Sympathomimetic bronchodilator

3. ACE inhibitor

4. Peroxisome Proliferator Receptor alpha Agonist

5. Benzodiazepine

6. Potassium Sparing Diuretic

1. prevent symptoms of asthma/COPD

2. treats asthma, bronchodilator, allows for better gas exchange

3. used to treat hypertension, lowers blood pressure

4. helps treat hyperlipidemia, lowers cholesterol and triglycerides

5. Treats anxiety, little to no anxiety

6. Increased urination without affecting potassium

One disease process often influences the development of other illnesses. Based on your knowledge of

pathophysiology, (if applicable), which disease likely developed FIRST that then initiated a “domino effect” in

their life?

  • put in bold what PMH problem likely started FIRST
  • Underline what PMH problem(s) FOLLOWED as domino(s) (anxiety could have happened at any part of her life span)
  1. II. Patient Care Begins:

Current VS:

WILDA Pain Scale (5th VS):

T: 103.2 (oral)

Words:

Ache

P: 110 (regular)

Intensity:

3/10

R: 30 (labored)

Location:

Generalized over right side of chest with no radiation

BP: 178/96

Duration:

Intermittent-lasting a few seconds

O2 sat: 86%

6 liters n/c

Aggreviate:

Alleviate:

Deep breath

Shallow breathing

What VS data is RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT VS Data:

Clinical Significance:

RR

O2

BP

Temperature

Heart Rate

 RR is increased which could be due to exacerbation of COPD/asthma and also possible fluid on the lungs (I would listen to her lungs to confirm this)

With her O2 sat I would first ask her what her baseline is. With COPD her baseline could run below normal. Then I would think that it is decreased even more due to the COPD/asthma exacerbation and fluid on the lungs

Temperature is increased due to probable infection

Heart Rate is increased due to probable infection and also possible anxiety and or pain

Current Assessment:

 

GENERAL

APPEARANCE:

Appears anxious and in distress

RESP:

Dyspnea with intercostal retractions, breath sounds very diminished bilaterally with

scattered expiratory wheezing

CARDIAC:

Pale, hot & dry, no edema, heart sounds regular-S1S2, pulses strong, equal with

palpation at radial/pedal/post-tibial landmarks

NEURO:

Alert & oriented to person, place, time, and situation (x4)

GI:

Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants

GU:

Voiding without difficulty, urine clear/yellow

SKIN:

Skin integrity intact

What assessment data is RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT Assessment Data:

Clinical Significance:

Appears to be in distress

Dyspnea with intercostals retractions

Diminished bilaterally with expiratory wheezing

Hot

 

12 Lead EKG:

Interpretation:

Sinus Tachycardia

Clinical Significance:

III. Clinical Reasoning Begins…

  1. What is the primary problem that your patient is most likely presenting with?

Respiratory infection with COPD/Asthma exacerbation

  1. What is the underlying cause/pathophysiology of this problem?

40 years of smoking

  1. What nursing priority(s) will guide your plan of care? (if more than one-list in order of PRIORITY)
  • O2 sat and RR
  • Blood pressure
  • Temperature
  1. What interventions will you initiate based on this priority?

Nursing Interventions:

Rationale:

Expected Outcome:

     
  1. What body system(s) will you most thoroughly assess based on the primary/priority concern?

Respiratory system

  1. What is the worst possible/most likely complication to anticipate?

Pneumothorax (people with chronic COPD are at higher risk for spontaneous pneumothorax)

Sepsis (infection gets into the blood stream)

  1. What nursing assessment(s) will you need to initiate to identify this complication if it develops?

Chest pain, SOB, Increased or decreased heart rate, increased or decreased temperature, decreased LOC, decreased urine output

  1. What nursing interventions will you initiate if this complication develops?

Medical Management: Rationale for Treatment & Expected Outcomes

Care Provider Orders:

Rationale:

Expected Outcome:

albuterol-ipratropium

(Combivent) 2.5 mg neb

Establish peripheral IV Lorazepam (Ativan) 1 mg IV

push

Methylprednisolone (Solumedrol) 125 mg IV push

Levofloxacin (Levaquin) 750 mg IVPB (after blood cultures drawn)

Acetaminophen (Tylenol)

1000mg oral

Chest x-ray (CXR) Complete cell count (CBC) Basic metabolic panel

   

(BMP) Lactate

Arterial blood gas (ABG)

Sputum culture with gram stain

Blood culture x2 sites

Urine analysis (UA) Urine culture (UC)

PRIORITY Setting: Which Orders Do You Implement First and Why?

Care Provider Orders:

Order of Priority:

Rationale:

1. Albuterol-ipratropium

(Combivent) 2.5 mg neb

2. Establish peripheral IV

3. Lorazepam (Ativan) 1 mg

IV push

4. Methylprednisolone

(Solumedrol) 125 mg IV

push

5. Levofloxacin (Levaquin)

750 mg IVPB (after blood cultures drawn)

6. Acetaminophen (Tylenol)

1000mg oral

1.

2.

3.

4.

5.

6.

1.

2.

3.

4.

5.

6.

Medication Dosage Calculation:

Medication/Dose:

Mechanism of Action:

Volume/time frame to

Safely Administer:

Nursing Assessment/Considerations:

lorazepam

(Ativan)

1 mg IV push

Normal Range:

(high/low/avg?)

 

IV Push: Volume every 15 sec?

 

Medication/Dose:

Mechanism of Action:

Volume/time frame to

Safely Administer:

Nursing Assessment/Considerations:

methylprednisolone

(Solumedrol)

125 mg IV push

Normal Range:

(high/low/avg?)

 

IV Push: Volume every 15 sec?

 

Medication/Dose:

Mechanism of Action:

Volume/time frame to

Safely Administer:

Nursing Assessment/Considerations:

levofloxacin

(Levaquin)

750 mg IVPB

Normal Range:

(high/low/avg?)

 

150 mL over 90

minutes

Hourly rate on pump:

 

Radiology Reports:

What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT Results:

Clinical Significance:

Left lower lobe infiltrate.

Hypoventilation present in both lung fields

 

Lab Results:

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

Complete Blood Count (CBC:)

Current:

High/Low/WNL?

Most Recent:

WBC (4.5-11.0 mm 3)

14.5

 

8.2

Hgb (12-16 g/dL)

13.3

 

12.8

Platelets(150-450x 103/µl)

217

 

298

Neutrophil % (42-72)

92

 

75

Band forms (3-5%)

5

 

1

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

     

Basic Metabolic Panel (BMP:)

Current:

High/Low/WNL?

Most Recent:

Sodium (135-145 mEq/L)

138

 

142

Potassium (3.5-5.0 mEq/L)

3.9

 

3.8

Chloride (95-105 mEq/L)

98

 

96

CO2 (Bicarb) (21-31 mmol/L)

35

 

31

Anion Gap (AG) (7-16 mEq/l)

15

 

16

Glucose (70-110 mg/dL)

112

 

102

Calcium (8.4-10.2 mg/dL)

8.9

 

9.7

BUN (7 - 25 mg/dl)

32

 

28

Creatinine (0.6-1.2 mg/dL)

1.2

 

1.0

Misc. Labs:

Current

High/Low/WNL?

Most Recent

Lactate (0.5-2.2 mmol/L)

3.2

   

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

     

Arterial Blood Gas:

Current:

High/Low/WNL?

pH (7.35-7.45)

7.25

 

pCO2 (35-45)

68

 

pO2 (80-100)

52

 

HCO3 (18-26)

36

 

O2 sat (>92%)

84%

 

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

     

Urine Analysis (UA:)

Current:

High/Low/WNL?

Color (yellow)

Yellow

 

Clarity (clear)

Clear

 

Specific Gravity (1.015-1.030)

1.015

 

Protein (neg)

Neg

 

Glucose (neg)

Neg

 

Ketones (neg)

Neg

 

Bilirubin (neg)

Neg

 

Blood (neg)

Neg

 

Nitrite (neg)

Neg

 

LET (Leukocyte Esterase) (neg)

Neg

 

MICRO:

   

RBC’s (<5)

1

 

WBC’s (<5)

3

 

Bacteria (neg)

Few

 

Epithelial (neg)

Few

 

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

     

Lab Planning: Creating a Plan of Care with a PRIORITY Lab:

Lab:

Normal value:

Why Relevant?

Nursing Assessments/Interventions Required:

Lactate

Value:

3.2

Critical Value:

   
  1. Evaluation:

One hour later…

You have been able to implement all orders and it has been 30 minutes since the nebulizer treatment. Your collect the

following clinical reassessment data:

Current VS:

Most Recent:

T: 100.8 (oral)

T: 103.2 (oral)

P: 88 (regular)

P: 110 (regular)

R: 24 (slight labored)

R: 30 (labored)

BP: 128/90

BP: 178/96

O2 sat: 92%

4 liters n/c

O2 sat: 86%

6 liters n/c

Current

Assessment:

 

GENERAL

APPEARANCE:

Resting comfortably, appears in no acute distress

RESP:

Breath sounds improved aeration bilaterally, coarse crackles with diminished aeration in

left lower lobe (LLL)

CARDIAC:

Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses

strong, equal with palpation at radial/pedal/post-tibial landmarks

NEURO:

Alert & oriented to person, place, time, and situation (x4)

GI:

Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants

GU:

Voiding without difficulty, urine clear/yellow

SKIN:

Skin integrity intact

  1. What clinical data is RELEVANT that must be recognized as clinically significant?

RELEVANT VS Data:

Clinical Significance:

   

RELEVANT Assessment Data:

Clinical Significance:

   

You report your assessment findings to the primary care provider who decides to repeat the ABG. You obtain the following results:

Arterial Blood Gas:

Current:

Most Recent:

pH (7.35-7.45)

7.31

7.25

pCO2 (35-45)

55

68

pO2 (80-100)

78

52

HCO3 (18-26)

35

36

O2 sat (>92%)

91%

84%

  1. Has the status improved or not as expected to this point?
  1. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
  1. Based on your current evaluation, what are your nursing priorities and plan of care?

It is now time to transfer your patient to the floor. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient:

Situation:

Background:

Assessment:

Recommendation:

  1. Education Priorities/Discharge Planning
  2. What will be the most important discharge/education priorities you will reinforce with their medical condition to prevent future readmission with the same problem?
  1. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?
  1. Caring and the “Art” of Nursing
  2. What is the patient likely experiencing/feeling right now in this situation?
  1. What can you do to engage yourself with this patient’s experience, and show that he/she matter to you as a person?
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