-Pneumonia-COPD Unfolding Reasoning PDF

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pneumonia COPD case ...

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Pneumonia-COPD

Joan Walker, 84 years old

Primary Concept Gas Exchange Interrelated Concepts (In order of emphasis) 1. 2. 3. 4. 5. 6. 7. 8.

© 2016 Keith Rischer/www.KeithRN.com

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

UNFOLDING Reasoning Case Study: STUDENT

Pneumonia-COPD History of Present Problem: Joan Walker is an 84-year-old female who has had a productive cough of green phlegm that started four days ago that persists. She was started three days ago on prednisone 40 mg PO daily and azithromycin (Zithromax) 250 mg PO x5 days by her clinic physician. Though she has had intermittent chills, she had a fever last night of 102.0 F/38.9 C. She has had more difficulty breathing during the night and has been using her albuterol inhaler every 1-2 hours with no improvement so she called 9-1-1 and was brought to the emergency department (ED) where you are the nurse who will be responsible for her care.

Personal/Social History: Joan was widowed six months ago after 64 years of marriage and resides in assisted living. She is a retired elementary school teacher. She called her pastor before coming to the ED 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 to her pastor, “Yes please, I feel that this may the beginning of the end for me!” What data from the histories is RELEVANT and has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: Productive cough of green phlegm X4days This may be the start of pneumonia. Her high fever and chills may be a Chill and fever overnight of 102. sign of infection. Her difficulty breathing could cause her to panic, not Difficulty of breathing overnight getting enough air is a scary situation to be in. Using the inhaler with no Use of inhaler q 1-2 hours no improvement improvement should be of concern to the nurse.

RELEVANT Data from Social History: Widowed Lives in assisted living Retired Feeling of hopelessness due to her comment of “yes please, I feel like this may be the beginning of the end for me”!

Clinical Significance: Her only support system is no longer by her side. Residing in assisted living is helpful, he can make new friends and enjoy social interaction. She is retired which means not as productive as she once was. She may not be getting outside as much or exercising as much. She sounds hopeless by her statement. She thinks she will not survive this hospital 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 1. corticosteroid 1. improve breathing diskus 1 puff every 12 hours 2. bronchodilator 2. open up airway in the 2. Albuterol MDI 2 puffs  Hyperlipidemia 3. ACE inhibitor lungs every 4 hours prn  Cor-pulmonale 4. cholesterol 3. decrease blood pressure 3. Lisinopril 10 mg PO daily  Anxiety 5. benzodiazepine and 4. Gemfribrozil 600 mg PO 6. potassium sparing open up blood vessels bid diuretic 4. decrease fatty acids 5. Diazepam 2.5 mg PO 5. decrease anxiety and every 6 hours as needed calm 6. Triamterene-HCTZ 1 tab down PO daily

6. help body from not absorbing too much salt and keep potassium level from getting too low.

One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in her life?  Circle what PMH problem likely started FIRST 

Underline what PMH problem(s) FOLLOWED as domino(s)

Patient Care Begins: Current VS: T: 103.2 F/39.6 C (oral) P: 110 (regular) R: 30 (labored) BP: 178/96 O2 sat: 86% 6 liters n/c

P-Q-R-S-T Pain Assessment (5th VS): Provoking/Palliative: Deep breath/Shallow breathing Ache Quality: Generalized over right side of chest with no radiation Region/Radiation: 3/10 Severity: Intermittent–lasting a few seconds Timing:

What VS data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: High temp Pulse is high Labored resps BP high O2 LOW despite being on 6 L per NC Breaths are deep and shallow Pain over R side of chest

This high temp could be a sign of infection. Pulse is also high which could be due to infection, fever, or anxiety. Respirations are very high and O2 is very low this is a main concern, she is not getting enough oxygen into her system and can become hypoxic and go into resp acidosis. Blood pressure is elevated, and she has a history of elevated BP and heart failure so BP mustbe monitored. Patient is in pain and seem to but is only stating 3/10 and achiness over the R side of chest.

Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: SKIN:

Appears anxious and in distress, barrel chest present Dyspnea with use of accessory muscles, breath sounds very diminished bilaterally ant/post 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, skin turgor elastic, no tenting present

What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: She is anxious and in distress Her general appearance is important because we can see that she is Barrel chest is present having difficulty breathing and is anxious. She is using her accessory muscles to Her respiratory assessment is important because again we can see that breath and has dyspnea. There is wheezing she is in distress and having a possible COPD exacerbation. With the and diminished lung sounds BILAT

wheezing and diminished lungs sounds she is retaining fluid and her lungs are filling up.

12 Lead EKG

Interpretation: Sinus tachy Clinical Significance: The fast HR is most likely DT the infection going on. Possible pneumonia. She could be dehydrated.

Chest x-ray: 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

Possible pneumonia or even sepsis. The hypoventilation is most likely DT a COPD exacerbation.

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

Previous: 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: All point to infection WBC worsening WBC Neutrophil Neutrophil worsening Band forms Band forms improving from previous labs.

Basic Metabolic Panel (BMP:)

Current:

High/Low/WNL?

Prior:

Sodium (135–145 mEq/L) Potassium (3.5–5.0 mEq/L) CO2 (Bicarb) (21–31 mmol/L) Glucose (70–110 mg/dL) BUN (7–25 mg/dl) Creatinine (0.6–1.2 mg/dL) Misc. Labs: Lactate (0.5–2.2 mmol/L)

138 3.9 35 112 32 1.2

WNL WNL HIGH HIGH HIGH WNL

142 3.8 31 102 28 1.0

3.2

HIGH

n/a

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: ALL WORSENING Bicarb COPD Glucose Prednisone BUN Renal Lactate Sepsis

Arterial Blood Gas:

Current:

pH (7.35–7.45) pCO2 (35–45) pO2 (80–100) HCO3 (18–26) O2 sat (>92%)

7.25 68 52 36 84%

High/Low/WNL? LOW ACIDIC HIGH HIGH HIGH LOW

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: ALL the ABGs are relevant She is in respiratory acidosis compensated.

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 RBCs (...