Pneumonia Case Study Basic Week 2 NURS 1140

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: Productive cough of green phlegm four days ago that persists. Started three days ago on prednisone 60 mg PO daily and azithromycin 250 mg PO x5 days by her clinic physician. Fever last night of 102.0 More difficulty breathing during the night and has been using her albuterol inhaler every 1-2 hours with no improvement Productive cough is a clinical manifestation. Sputum in shades of yellow- green indicates bacterial infection. This respiratory infection was treated by an antibiotic and steroids. Nurse determine if treatment was effective, Response to bacterial infection. Inflammatory response. Recurrent pneumonia is a common complication of COPD and a frequent cause of COPD exacerbation RELEVANT Date from Social History Clinical Significance 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!” Joan values spirituality. Spirituality is important to patient and the nurse must be sensitive Emotional support will be a priority for disease 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: T: 103.2 F/39.6 C (oral) Elevated due to infection P: 110 (regular) Elevated due to stress R: 30 (labored) Elevated due to Pneumonia/COPD BP: 178/96 Elevated due to anxiety and stress O2 sat: 86% 6 liters n/c Elevated O2 is contraindicated in patients Pain: 3/10, ache, generalized over right side with COPD of chest with no radiation, intermittentlasting Pain level still should be assessed and a few secs monitored, 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 RELEVAN