Pneumonia-COPD case study solutions PDF

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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. Thermoregulation V. VII. VIII. IX.

Gas Exchange Infection Acid-Base Balance Clinical Judgment VI. 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:

Fever, difficulty breathing, no improvement This is important because we need to look at the relevant data and with the inhaler, productive cough of green realize that she seems to be in distress and first take care of that. Also phlegm. realize that she seems to have an infection. With this information we are able to prioritize RELEVANT Data from Social History:

Clinical Significance:

She was widowed 6 months ago after being This is important because when caring for her we need to keep in married for 64 years, and she feels like it is mind her age, stressors in her life and any limitations the beginning of the end for her.

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: 1. Fluticasone/salmeterol 1. corticosteroid 1. improve breathing  COPD/asthma (Advair) diskus 1 puff every 2. bronchodilator 2. open up airway in the lungs  Hypertension 12 hours 3. ACE inhibitor 3. decrease blood pressure and  Hyperlipidemia 2. Albuterol (Ventolin) MDI 4. cholesterol open up blood vessels  Cor-pulmonale 2 puffs every 4 hours prn 5. benzodiazepine 4. decrease fatty acids  Anxiety disorder 3. Lisinopril (Prinivil) 10 mg 6. potassium sparing diuretic 5. decrease anxiety and calm  1ppd smoker x40 years. po daily down Quit 10 years ago 4. Gemfribrozil (Lopid) 600 6. help body from not mg po bid absorbing too much salt and 5. Diazepam (Valium) 2.5 keep potassium level from mg po every 6 hours as getting too low. needed 6. Triamterene-HCTZ (Dyazide) 1 tab daily 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:

Temperature, pulse, The temperature is high which signifies infection. Pulse is also high which could be respirations, blood due to infection, fever or anxiety. Respriations are very high and O2 is very low this is a pressure, O2 sat, location main concern, she is not getting enough oxygen into her system and can become hypoxic and go into resp acidocis. Blood pressure is elevated and she has a history of of pain, and what aggravates and alleviates elevated BP and heart failure so it needs to be monitored. Patient is in pain and seem to be related to her lungs. 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:

General appearance, respiratory, and cardiac

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:

Interpretation:

Sinus tachycardia Clinical Significance:

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?

Pneumonia with COPD exacerbation and possible sepsis 2. What is the underlying cause/pathophysiology of this problem?

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. What nursing priority(s) will guide your plan of care? (if more than one-list in order of PRIORITY)

Breathing, O2, BP, HR, temperature

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

Increase oxygen (8-10 L on mask or nonrebreather). Place on a cooling blanket. Inform doctor of BP.

Expected Outcome:

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

Increase O2 to at least 90%. decrease her temperature. decrease her BP.

5. What body system(s) will you most thoroughly assess based on the primary/priority concern? Respiratory 6. What is the worst possible/most likely complication to anticipate?

Sepsis or pneumothorax 7. What nursing assessment(s) will you need to initiate to identify this complication if it develops?

Sepsis- Temp, HR, BP, lactic acid. Pneumothorax-SOB, CP 8. What nursing interventions will you initiate if this complication develops?

Sepsis- follow hospital procedure. Pneumothorax- call DR and prepare to insert a chest tube. (this is emergent)

Medical Management: Rationale for Treatment & Expected Outcomes Care Provider Orders: albuterol-ipratropium (Combivent) 2.5 mg neb Establish peripheral IV Lorazepam (Ativan) 1 mg IV push Methylprednisolone (Solumedrol) 125 mg IV push

Rationale:

Expected Outcome:

Bronchodilator.

Open up airway to increase O2.

Access for medications.

Have IV access

Help with anxiety.

Decrease anxiety

Decrease bronchoconstriction.

Increase oxygen going to lungs.

Antibiotic.

Decrease WBC and temp

Decrease temperature.

Decrease temp

Levofloxacin (Levaquin) 750 mg IVPB (after blood cultures Check the lungs to see what is going on. drawn) Acetaminophen (Tylenol) 1000mg oral Chest x-ray (CXR) Complete cell count (CBC) Basic metabolic panel

Help detect if there is an infection going on.

Pleural effusion Increase in WBC, RBC and lactate

Look at the electrolytes, BUN, Creat, glucose, etc. Increase in glucose

(BMP)

Possible sepsis

Increase in lactate

Lactate

Tell you if there is pneumonia

Arterial blood gas (ABG)

Tell you if the infection is in the blood

Decrease ph, co2, respiratory acidosis.

Sputum culture with gram stain

Check the urine for cells, protein, sugar or blood

Positive Positive

See if the infection is a UTI

Blood culture x2 sites

Negative

Urine analysis (UA)

Negative

Urine culture (UC)

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

Order of Priority: 1. 1

Rationale: 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.

Medication Dosage Calculation: Medication/Dose:

lorazepam (Ativan) 1 mg IV push

Mechanism of Action:

Depress CNS by GABA

Average

Medication/Dose:

methylprednisolone (Solumedrol) 125 mg IV push high

Nursing Assessment/Considerations:

Fall risk, possible addiction, monitor respirations. IV Push: Volume every 15 sec? 2-5 minutes

Normal Range:

Normal Range:

Volume/time frame to Safely Administer:

Mechanism of Action:

Corticosteroid decreases inflammation of the bronchial

Volume/time frame to Nursing Assessment/Considerations: Safely Administer:

Adrenal insufficient, monitor I&O, weight patient daily. IV Push: Volume every 15 sec? None

Medication/Dose:

levofloxacin (Levaquin) 750 mg IVPB

Mechanism of Action:

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: 100ml/hr

Normal Range: average

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. Buildup of fluid, bacterial infection. Hypoventilation- COPD 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:) WBC (4.5-11.0 mm 3) Hgb (12-16 g/dL) Platelets(150-450x 103/µl) Neutrophil % (42-72) Band forms (3-5%)

Current: 14.5 13.3 217 92 5

High/Low/WNL?

High WNL WNL High WNL

Most Recent: 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)

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

High/Low/WNL?

WNL WNL WNL High WNL High WNL High WNL High/Low/WNL?

High

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

RELEVANT Lab(s): Bicarb Glucose BUN Lactate

Clinical Significance: COPD Prednisone Renal Sepsis

Arterial Blood Gas: pH (7.35-7.45) pCO2 (35-45) pO2 (80-100) HCO3 (18-26) O2 sat (>92%)

RELEVANT Lab(s): All of them

Current: 7.25 68 52 36 84%

High/Low/WNL?

Low High Low High low

Clinical Significance: TREND: Improve/Worsening/Stable: Partially compensated respiratory acidosis N/A

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 (...