COPD CASE Study Complete PDF

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NURSING...

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Airway/Breathing (Oxygenation)

Pneumonia/Chronic Obstructive Pulmonary Disease Clinical Reasoning Case Study STUDENT Worksheet

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) I. II. III. IV. V. VI. VII. VIII. IX.

Gas Exchange Infection Acid-Base Balance Thermoregulation Clinical Judgment Pain Patient Education Communication Collaboration

Pneumonia-COPD

I. Data Collection History of Present Problem: 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 These vital signs clinically show signs of infection. With the Chills difficulty breathing I would think about possible respiratory Fever (102.0) infection Difficulty Breathing (no improvement with albuterol) RELEVANT Data from Social History:

84 years old Live in assisted living facility religious preference

Clinical Significance:

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 1. Fluticasone/salmeterol (Advair) diskus 1 puff every 1. corticosteroid, beta 2  Hypertension 1. prevent symptoms of 12 hours adrenergic agonist asthma/COPD  Hyperlipidemia 2. Albuterol (Ventolin) MDI 2. Sympathomimetic 2. treats asthma,  Cor-pulmonale 2 puffs every 4 hours prn bronchodilator bronchodilator, allows for  Anxiety disorder 3. Lisinopril (Prinivil) 10 mg better gas exchange  1ppd smoker x40 years. po daily 3. ACE inhibitor Quit 10 years ago 4. Gemfribrozil (Lopid) 600 4. Peroxisome Proliferator 3. used to treat hypertension, mg po bid Receptor alpha Agonist lowers blood pressure 5. Diazepam (Valium) 2.5 5. Benzodiazepine 4. helps treat hyperlipidemia, mg po every 6 hours as 6. Potassium Sparing lowers cholesterol and needed Diuretic triglycerides 6. Triamterene-HCTZ (Dyazide) 1 tab daily 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?  Circle what PMH problem likely started FIRST  Underline what PMH problem(s) FOLLOWED as domino(s)

II. Patient Care Begins: Current VS: T: 103.2 (oral) P: 110 (regular) R: 30 (labored) BP: 178/96 O2 sat: 86% 6 liters n/c

WILDA Pain Scale (5th VS): Words: Ache Intensity: 3/10 Location: Generalized over right side of chest with no radiation Duration: Intermittent-lasting a few seconds Aggreviate: Deep breath Shallow breathing Alleviate:

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: RESP: CARDIAC: NEURO: GI: GU: SKIN:

Appears anxious and in distress Dyspnea with intercostal retractions, breath sounds very diminished bilaterally with scattered expiratory wheezing Pale, hot & dry, no edema, heart sounds regular-S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks Alert & oriented to person, place, time, and situation (x4) Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants Voiding without difficulty, urine clear/yellow 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

Her general appereance is important because we can see that she is having difficulty breathing and is anxious. Her respiratory assessment is important because again we can see that she is in distress and having a possible asthma exacerbation. Also by listening we can hear that she has some fluid on her lungs With her cardiac assessment we can see that she has a fever

12 Lead EKG:

Sinus tachycardia Clinical Significance: Increased heart rate.

Tachycardia can be due to many possible explanations such as infection, anxiety or fever. All of which are all very likely for this patient.

III. Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with? Respiratory infection with COPD/Asthma exacerbation

2. What is the underlying cause/pathophysiology of this problem? 40 years of smoking

Pneumonia is an infection in which the lungs contain fluid or piss caused by many different things such as bacteria, fungi, parasites and more. 3. List all relevant nursing priorities. 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

4. What interventions will you initiate based on this priority? Nursing Interventions:

Rationale:

Increase oxygen (8-10 L on mask or nonrebreather).

Expected Outcome:

6L was not enough because he sat was only Increase O2 to at least 90%. 86%. To decrease the temperature without having to give too much medication for it. decrease her temperature. To see if they want to give any medication for it. decrease her BP.

Place on a cooling blanket.

Inform doctor of BP.

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

6. 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)

7. 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

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

Medical Management: Rationale for Treatment & Expected Outcomes Care Provider Orders: 1. albuterolipratropium (Combivent) 2.5 mg neb 2. Establish peripheral IV 3. Lorazepam (Ativan) 1 mg IV push

Rationale:

1. Bronchodilator.

1. Open up airway to increase O2.

2. Access for medications. 2. Have IV access 3. Help with anxiety 3. Decrease anxiety 4. Decrease bronchoconstriction.

4. Methylprednisolo ne (Solumedrol) 125 mg IV push

5. Antibiotic.

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

7. Check the lungs to see what is going on.

6. Acetaminophen

Expected Outcome:

6. Decrease temperature.

8. Help detect if there is an infection going on.

4. Increase oxygen going to lungs. 5. Decrease WBC and temp 6. Decrease temp 7. Pleural effusion

(Tylenol) 1000mg oral

9. Look at the electrolytes, BUN, Creat, glucose, etc.

8. Increase in WBC, RBC and lactate

Complete cell count

10. Possible sepsis

9. Increase in glucose

(CBC)

11. Tell you if there is pneumonia

10. Increase in lactate

12. Tell you if the infection is in the blood

11. Decrease ph, co2, respiratory acidosis.

7. Chest x-ray (CXR)

13. Check the urine for cells, protein, sugar or blood See if the infection is a UTI

12. Positive 13. Positive 14. Negative 15. Negative

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

8. Basic metabolic panel (BMP) 9. Lactate 10. Arterial blood gas (ABG) 11. Sputum culture with gram stain

Order of Priority:

Rationale:

1. 1

1. airway first r/t ABC’s

2. 2

2. have access for medications

3. 3

3. to help calm down and breathe easier

4. 4

4. breathing is always one of the top priorities

5. 5

5. start broad spectrum antibiotics to get in the system and help fight infection.

6. 6 6. won’t act as fast so you can do last.

12. Blood culture x2 sites Urine analysis (UA) 13. Urine culture (UC) Medication/Dose: Mechanism of Action:

lorazepam (Ativan) 1 mg IV push

Depress CNS by GABA IV Push: Volume every 15 sec?

Normal Range: average

Nursing Assessment/Considerations:

Volume/time frame to Safely Administer:

Fall risk, possible addiction, monitor respirations.

2-5 minutes

(high/low/avg?)

Medication/Dose:

Mechanism of Action:

methylprednisolone (Solumedrol) Corticosteroid decreases 125 mg IV push inflammation of the bronchial Normal Range: high

Volume/time frame to Safely Administer:

IV Push: Volume every 15 sec?

(high/low/avg?)

Nursing Assessment/Considerations:

Adrenal insufficient, monitor I&O, weight patient daily.

none

Medication/Dose:

Mechanism of Action:

levofloxacin (Levaquin) 750 mg IVPB

Broad spectrum antibiotic

Volume/time frame to Safely Administer:

150 mL over 90 minutes

Nursing Assessment/Considerations:

Photo toxicity, muscle weakness, and hepatic toxic.

Hourly rate on pump:

Normal Range: average (high/low/avg?)

100ml/hr

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 Buildup of fluid, bacterial infection. Hypoventilation- COPD 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) Hgb (12-16 g/dL) Platelets(150-450x 103/µl) Neutrophil % (42-72) Band forms (3-5%)

14.5 13.3 217 92 5

high WNL WDL HIGH WDL

8.2 12.8 298 75 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: WBC

Infection

WBC increasing

Neutrophil

Neutrophil increasing

Band forms

Band forms improving

Basic Metabolic Panel (BMP:) Sodium (135-145 mEq/L) Potassium (3.5-5.0 mEq/L) Chloride (95-105 mEq/L) CO2 (Bicarb) (21-31 mmol/L) Anion Gap (AG) (7-16 mEq/l) Glucose (70-110 mg/dL) Calcium (8.4-10.2 mg/dL) BUN (7 - 25 mg/dl) Creatinine (0.6-1.2 mg/dL) Misc. Labs: Lactate (0.5-2.2 mmol/L)

RELEVANT Lab(s):

Current: 138 3.9 98 35 15 112 8.9 32 1.2 Current 3.2

High/Low/WNL? WDL WDL WDL HIGH WDL HIGH WDL HIGH WDL

High/Low/WNL?

Most Recent: 142 3.8 96 31 16 102 9.7 28 1.0 Most Recent

HIGH

Clinical Significance:

TREND: Improve/Worsening/Stable:

Bicarb

COPD

Increasing

Glucose

Prednisone

Increasing

BUN

Renal

Increasing

Lactate

Sepsis

N/A

Arterial Blood Gas: pH (7.35-7.45)

Current: 7.25

High/Low/WNL?

LoW pCO2 (35-45) pO2 (80-100) HCO3 (18-26) O2 sat (>92%)

RELEVANT Lab(s):

68 52 36 84%

Clinical Significance:

High Low High LOW

TREND: Improve/Worsening/Stable:

N/A

All of them

Partially compensated respiratory acidosis

Urine Analysis (UA:) Color (yellow) Clarity (clear) Specific Gravity (1.015-1.030) Protein (neg) Glucose (neg) Ketones (neg) Bilirubin (neg) Blood (neg) Nitrite (neg) LET (Leukocyte Esterase) (neg) MICRO: RBC’s (...