CASE STUDY - MedSurge - COPD w/ Pneumonia - Darrell Johnson

CASE STUDY - MedSurge - COPD w/ Pneumonia - Darrell Johnson 62M comes to ED w/a 4 day history of increased sputum production, change in character of sputum, increased SOB, and fever 101F. History of smoking 2packs/day ...

CASE STUDY - MedSurge - COPD w/ Pneumonia - Darrell Johnson 62M comes to ED w/a 4 day history of increased sputum production, change in character of sputum, increased SOB, and fever 101F. History of smoking 2packs/day prior, beginning at age 14. He reports he had asthma as a child and he's been treated with Albuterol inhalers as an adult. Has been hospitalized 2x w/pneumonia; the most recent was 2 years ago. Physical exam: VS: 101F, P 115, R 30, BP 120/80 Respirations shallow and labored, w/use of accessory muscles Increased AP diameter of chest Skin dry and warm touch, inelastic skin turgor, fingernail clubbing. Which assessment is most important for nurse to complete next? Auscultate breath sounds RATIONALE: This is the highest priority because Mr. Johnson is clearly exhibiting respiratory distress Which assessment finding supports pt's diagnosis of pneumonia Pulse of 110-- tachycardia is most consistent w/infectious process, in addition pt's fever and rapid RR are also VS findings that indicate a problem--> infection RATIONALE: Tachycardia is consistent with an infectious process. In addition, Mr. Johnson's fever and rapid respiratory rate are also vital sign findings that indicate a problem, such as an infection. Crackles ABG: pH 7.28 pCO2 55 HCO3 25 pO2 89 These ABG results indicate that pt is experiencing which acid-base imbalance Respiratory acidosis-- RATIONALE: The low pH indicates that acidosis is present. The elevated pCO2 indicates that the problem is respiratory in nature. Clients w/any condition that depresses respirations are prone to the development of respiratory acidosis. Even though pt has a rapid RR, his underlying COPD causes retention of CO2 Which nursing diagnosis has the highest priority when the nurse is planning care for pt? Ineffective airway clearance RATIONALE: There are adventitious breath sounds, tachypnea, changes in depth of respirations, fever, and cough, all of which support this as a priority diagnosis. Pt admitted and HCP prescribes: -Bedrest w/bedside commode -O2 at 2L/min nasal cannula -diet as tolerated -continuous O2 sat monitoring via pulse oximeter -IV fluid 5%Dextrose and 0.45% NS at 3L/day -obtain sputum culture Meds: -ampicillin 1gm IVPB Q6H -Neb Tx Q4H and prn saline & albuterol - beclomethasone inhaler 2puffs 2x/day -albuterol 2puffs 4x/day methylprednisolone 125mg IVPB Q8H Which nursing action should be implemented before Ampicillin is administered? Obtain sputum culture-- RATIONALE: the sputum culture will be compromised if broad-spectrum is taken first. The sputum specimen should The levofloxacin 500 mg IVPB is supplied in 100 mL of D5W to be delivered over 60 minutes. There is no IV pump available so the nurse will infuse the antibiotic by gravity. The drop factor on the tubing is 20 gtts/mL. The nurse should set the IVIVPB to infuse at how many gtts per min? (Enter numerical value only. If rounding is necessary, round to the whole number.) 33 RATIONALE: V x gtt factor/time (minutes) 100 mL x 20 min/60 min = 33.33 (33 rounded to whole number) Which assessment is most important for nurse to perform while pt is receiving albuterol? Monitor pulse and BP