IHUMAN Pneumonia Case Study Joan Walker, 84 years old,100% CORRECT

Keiser University: IHUMAN Pneumonia Case Study Joan Walker, 84 years old Pneumonia-COPD Joan Walker, 84 years old Primary Concept Gas Exchange Interrelated Concepts (In order of emphasis) 1. Infection 2. Aci ...

Keiser University: IHUMAN Pneumonia Case Study Joan Walker, 84 years old Pneumonia-COPD Joan Walker, 84 years old Primary Concept Gas Exchange Interrelated Concepts (In order of emphasis) 1. Infection 2. Acid-Base Balance 3. Thermoregulation 4. Clinical Judgement 5. Pain 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 continues to persist. 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 last night and has been using her albuterol inhale every 1-2 hours with no improvement so she called 9-1-1 and is 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 be 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: Fever, difficulty breathing, no improvement with the inhaler, intermittent chills, productive cough of green phlegm. She seems to be in distress so this needs to be addressed. Her temp, fever and intermittent chills indicate that an infection may be present. RELEVANT Date from Social History Clinical Significance Widowed 6 months ago after being married for 64 years and feels like her life is about to end. These factors may be contributing stress for the patient. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 103.2 F/39.6 C (oral) Provoking/Palliative: Deep breath/Shallow breathing P: 110 (regular) Quality: Ache R: 30 (labored) Region/Radiation: Generalized over right side of chest with no radiation BP: 178/96 Severity: 3/10 O2 sat: 86% 6 liters n/c Timing: Intermittent-lasting a few seconds What VS data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data Clinical Significance: Temp, pulse, Elevated temp signifies an infection is present. The elevated pulse respirations, BP, O2 sat, location of her pain, provoking/palliative may be due to the infection as well, fever, or anxiety. Resp are elevated and O2 is low. This is a concern because she can become hypoxic and go into respiratory acidosis. BP is elevated and she may factors have a hx of elevated BP and HF so she should be asked about it and monitored. Her pain seems to be related to her lungs because it is provoked when she breathes dep. Current Assessment: GENERAL APPEARANCE: Appears anxious and in distress, barrel chest present RESP: Dyspnea with use of accessory muscles, breath sounds very diminished bilaterally and/post with scattered expiratory wheezing CARDIAC: Pale, hot & dry, no edema, heart sounds regular—S1S1, 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, 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: General appearance, respiratory, cardiac Her general appearance shows she is anxious, and a barrel chest is present. This should be monitored. Her respiratory assessment allows us to see that she is definitely in distress and may be having asthma exacerbation. Her cardiac assessment shows that she has a fever. 12 Lead EKG Interpretation: Clinical Significance: 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. Buildup of fluid, bacterial infection, Hypoventilation - COPD 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? Prior: WBC (4.5-11.0 mm 3) 14.5 High 8.2 Hgb (12-16 g/dL) 13.3 WNL 12.8 Platelets (150-450x 103/μl) 217 WNL 298 Neutrophil % (42-72) 92 High 75 Band forms (3-5%) 5 WNL 1 What lab results are RELEVANT that must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: WBC, Neutrophil, Band forms Infection WBC increasing, neutrophils increasing, Band forms improving Basic Metabolic Panel (BMP): Current: High/Low/WNL? Prior: Sodium (135-145 mEq/L) 138 WNL 142 Potassium (3.5-4.5 mEq/L) 3.9 WNL 3.8 CO2 (Bicarb) (21-31 mmol/L) 35 High 31 Glucose (70-110 mg/dL) 112 High 102 BUN (7-25 mg/dl) 32 High 28 Creatinine (0.6-1.2 mg/dL) 1.2 WNL 1.0 Misc. Labs: Current: High/Low/WNL? Prior: Lactate (0.5-2.2 mmol/L) 3.2 High n/a What lab results are RELEVANT that must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: CO2: 35 mmol/L Glucose: 112 mg/dL COPD Prednisone related Increasing Increasing BUN: 32 mg/dl Renal function Increasing Lactate: 3.2 mmol/L Sign of sepsis N/A Arterial Blood Gas: Current: High/Low/WNL? pH (7.35-7.45) 7.25 Low pCO2 (35-45) 68 High pO2 (80-100) 52 Low HCO3 (18-26) 36 High O2 sat (>92%) 84% Low What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: All arterial lab values Partially compensated respiratory acidosis Urine Analysis (UA) Current: High/Low/WNL? Color (yellow) Yellow WNL Clarify (clear) Clear WNL Specific Gravity (1.015-1.030) 1.015 WNL Protein (neg) Neg WNL Glucose (neg) Neg WNL Ketones (neg) Neg WNL Bilirubin (neg) Neg WNL Blood (neg) Neg WNL Nitrite (neg) Neg WNL LET (Leukocyte Esterase) (neg) Neg WNL MICRO RBCs (<5) 1 WNL WBCs (<5) 3 WNL Bacteria (neg) Few High Epithelial (neg) Few High What lab results are RELEVANT that must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Bacteria Epithelial Only few are present so it is currently okay but should be monitored to ensure it does not increase. N/A 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 tis primary problem? Pneumonia is an infection in which the lungs contain fluid caused by a variety of factors such as bacteria, fungi, and parasites. Collaborative Care: Medical Management Care Provider Orders: Rationale: Expected outcomes: 1. Albuterol-ipratropium 2.5 mg neb 2. Establish peripheral IV 3. Lorazepam 1 mg IV push every 6 hours prn anxiety 4. Methylprednisolone 125 mg IV push 5. Levofloxacin 750 mg IVPB (after blood cultures drawn) 6. Acetaminophen 1000mg oral 1. Bronchodilator 2. Access for medication administration 3. Helps with anxiety 4. decreases bronchoconstriction 5. antibiotic to treat pneumonia 6. decrease temp 1. O2 will increase because airways will open 2. IV access 3. decrease patient’s anxiety level 4. increase the oxygen going to the lungs 5. decrease WBC and temp 6. decrease temp PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale: 1. Albuterol-ipratropium 2.5 mg neb I would prioritize exactly how they are listed. 1. ABCs – airway takes precedent 2. access for medication administration 3. helps patient calm down and breathe easier 4. breathing is always a top priority 5. this is a broad-spectrum antibiotic that will help fight the infection once it is in her system. 6. does not take effect quickly so it can be administered last. 2. Establish peripheral IV 3. Lorazepam 1 mg IV push 4. Methylprednisolone 125 mg IV push 5. Levofloxacin 750 mg IVPB (after blood cultures drawn) 6. Acetaminophen 1000mg PO Collaborative Care: Nursing 3. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY) Breathing, O2, BP, HR, temp 4. What interventions will you initiate based on this priority? Nursing Interventions Rationale: Expected Outcomes: Increase oxygen (maybe use nonrebreather instead of n/c) Place on a cooling blanket. She is not receiving enough O2 currently. Decrease temp without the O2 will increase to 90%. Her temp will decrease. use of additional medications Consult the doctor regarding The doctor may want to Her BP will decrease. BP prescribe a medication 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? Sepsis or pneumothorax 7. What nursing assessments will identify this complication EARLY if it develops? Sepsis: temp, HR, BP, lactic acid Pneumothorax: SOB, chest pain 8. What nursing interventions will you initiate if this complication develops? Sepsis: check the hospitals policies and procedures. Pneumothorax: call doctor and prepare to insert a chest tube. 9. What psychosocial needs will this patient and/or family have that will need to be addressed? Knowledge and education about what is taking place Emotional support Spiritual support 10. How will the nurse address these psychosocial needs? Knowledge and education regarding illness and plan of care - The nurse can integrate patient/family education naturally while providing care by simply explaining at their level everything that the nurse/physician has ordered and why it needs to be done. Spiritual Support - Spiritual care/support will be limited to encouragement, providing hope, and determining if the patient would like to have a chaplain or their spiritual leader notified. Emotional support -Being present and available for the patient and their family - Once admitted, it would be appropriate to ask open-ended questions to assess Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? The patient is probably anxious and. Supporting the patient and family by giving them as much information about their current status and explaining the plan of care is important . 2. What can you do to engage yourself with this patient’s experience and show that she matters to you as a person? Acknowledging Joan spiritually and offering support. Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgement. 1. What did you learn from this scenario? I learned that Pneumonia and COPD are critical diseases and should be assessed 2. How can I use what has been learned from this scenario to improve patient care in the future? I will use this to help me in the future create a care plan for Pneumonia and COPD patients and use my new knowledge to support the patient.