Pneumonia/Chronic Obstructive Pulmonary Disease Clinical Reasoning Case Assignment

Airway/Breathing (Oxygenation){" "} Pneumonia/Chronic Obstructive Pulmonary Disease Clinical Reasoning Case Assignment

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.

C o ncepts (in order of emphasis)

I. Gas Exchange
II. Infection

III. Acid-Base Balance

IV. Thermoregulation V. Clinical Judgment VI. Pain

VII. Patient Education

VIII. Communication

IX. Collaboration

Data Collection

H i story 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.

P e rsonal/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?

RELEVAN T Data from Present Problem:	C li nical 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
RELEVAN T Data from Social History:	C li nical 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?

( W hich medication treats which condition? Draw lines to connect)

P M H :

H ome Meds:

P harm. Classification:

E x pected Outcome:

· CO PD/asthma

· H y pertension

· H y perlipidemia

· C or-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

O ne 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

t heir 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)

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?

RELEVAN T VS Data:

C li nical Significance:

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?

RELEVAN T Assessment Data:

C li nical Significance:

Appears to be in distress

Dyspnea with intercostals retractions

Diminished bilaterally with expiratory wheezing

Hot

12 Lead EKG:

Interpretation:

Sinus Tachycardia

C li nical Significance:

III. Clinical Reasoning Begins…

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

Respiratory infection with COPD/Asthma exacerbation

{" "} What is the underlying cause/pathophysiology of this problem?

40 years of smoking

{" "} What nursing priority(s) will guide your plan of care?{" "} ( i f more than one-list in order of PRIORITY)

O2 sat and RR

Blood pressure

Temperature

{" "} What interventions will you initiate based on this priority?

N ursing Interventions:	R ationale:	E x pected Outcome:

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

Respiratory system

{" "} 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)

{" "} 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

What nursing interventions will you initiate if this complication develops?

M edical Management: Rationale for Treatment & Expected Outcomes

C are Provider Orders:

R ationale:

E x pected 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)

PR I ORITY Setting: Which Orders Do You Implement First and Why?

C are Provider Orders:

O rder of Priority:

R ationale:

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

M edication Dosage Calculation:

Medication/Dose:

Mechanism of Action:

V olume/time frame to

Safely Administer:

Nursing Assessment/Considerations:

lorazepam

(Ativan)

1 mg IV push

N ormal Range:

(high/low/avg?)

I V Push: Volume every 15 sec?

Medication/Dose:

Mechanism of Action:

V olume/time frame to

Safely Administer:

Nursing Assessment/Considerations:

me thylprednisolone

(Solumedrol)

125 mg IV push

N ormal Range:

(high/low/avg?)

I V Push: Volume every 15 sec?

Medication/Dose:

Mechanism of Action:

V olume/time frame to

Safely Administer:

Nursing Assessment/Considerations:

levofloxacin

(Levaquin)

750 mg IVPB

N ormal Range:

(high/low/avg?)

150 mL over 90

m inutes

Hourly rate on pump:

R a diology 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?

C omplete Blood Count (CBC:)	C urrent:	Hi gh/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:

B asic Metabolic Panel (BMP:)	C urrent:	Hi gh/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:	C urrent	Hi gh/Low/WNL?	Most Recent
Lactate (0.5-2.2 mmol/L)	3.2

RELEVANT Lab(s):	Clinical Significance:	TREND: Improve/Worsening/Stable:

A rterial Blood Gas:	C urrent:	Hi gh/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:

U rine Analysis (UA:)	C urrent:	Hi gh/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:

L ab:

N ormal value:

Why Relevant?

N ursing Assessments/Interventions Required:

Lactate

V alue:

3 .2

C ritical Value:

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:	M ost 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

{" "} What clinical data is RELEVANT that must be recognized as clinically significant?

RELEVAN T VS Data:	C li nical Significance:

RELEVAN T Assessment Data:	C li nical Significance:

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

A rterial Blood Gas:	C urrent:	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%

{" "} Has the status improved or not as expected to this point?

{" "} Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?

{" "} 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:

Education Priorities/Discharge Planning
{" "} What will be the most important discharge/education priorities you will reinforce with their medical condition to prevent future readmission with the same problem?

{" "} What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?

{" "} Caring and the “Art” of Nursing
{" "} What is the patient likely experiencing/feeling right now in this situation?

{" "} What can you do to engage yourself with this patient’s experience, and show that he/she matter to you as a person?