lCASE STUDY WEEK 10 JOANN WALKER, 84 YEARS
OLD PNEUMONIA/CHRONIC OBSTRUCTIVE
PULMONARY DISEASE CLINICAL REASONING CASE
STUDY
OMoARcPSD| 28697339
CASE STUDY WEEK 10 JOANN WALKER, 84 YEARS
OLD PNEUMONIA/CHRONIC OBSTRUCTIVE
PULMONARY DISEASE CLINICAL REASONING CASE
STUDY
AIRWAY/BREATHING (OXYGENATION)
, lCASE STUDY WEEK 10 JOANN WALKER, 84 YEARS
OLD PNEUMONIA/CHRONIC OBSTRUCTIVE
PULMONARY DISEASE CLINICAL REASONING CASE
STUDY
OMoARcPSD| 28697339
CASE STUDY
STUDENT Worksheet
JoAnn Walker, 84 years old
PNEUMONIA/CHRONIC OBSTRUCTIVE
PULMONARY DISEASE CLINICAL REASONING
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.
Concepts (in order of emphasis)
, lCASE STUDY WEEK 10 JOANN WALKER, 84 YEARS
OLD PNEUMONIA/CHRONIC OBSTRUCTIVE
PULMONARY DISEASE CLINICAL REASONING CASE
STUDY
OMoARcPSD| 28697339
I. Gas Exchange II. Infection
III. Acid-Base Balance
IV. Thermoregulation V. Clinical Judgment VI. Pain VII. Patient
Education VIII. Communication IX. Collaboration
Pneumonia-COPD
I. Data Collection
History of Present Problem:
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.
Personal/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?
RELEVANT Data from Present Problem: Clinical Significance:
Fever, difficulty breathing, no improvementThis is important because we need to look at the relevant data and
with the inhaler, productive cough of green realize that she seems to be in distress and first take care of that. Also
phlegm. realize that she seems to have an infection. With this information we
are able to prioritize
RELEVANT Data from Social History: Clinical Significance:
She was widowed 6 months ago after being This is important because when caring for her we need to keep in
married for 64 years, and she feels like it is mind her age, stressors in her life and any limitations the
beginning of the end for her.
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:
OLD PNEUMONIA/CHRONIC OBSTRUCTIVE
PULMONARY DISEASE CLINICAL REASONING CASE
STUDY
OMoARcPSD| 28697339
CASE STUDY WEEK 10 JOANN WALKER, 84 YEARS
OLD PNEUMONIA/CHRONIC OBSTRUCTIVE
PULMONARY DISEASE CLINICAL REASONING CASE
STUDY
AIRWAY/BREATHING (OXYGENATION)
, lCASE STUDY WEEK 10 JOANN WALKER, 84 YEARS
OLD PNEUMONIA/CHRONIC OBSTRUCTIVE
PULMONARY DISEASE CLINICAL REASONING CASE
STUDY
OMoARcPSD| 28697339
CASE STUDY
STUDENT Worksheet
JoAnn Walker, 84 years old
PNEUMONIA/CHRONIC OBSTRUCTIVE
PULMONARY DISEASE CLINICAL REASONING
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.
Concepts (in order of emphasis)
, lCASE STUDY WEEK 10 JOANN WALKER, 84 YEARS
OLD PNEUMONIA/CHRONIC OBSTRUCTIVE
PULMONARY DISEASE CLINICAL REASONING CASE
STUDY
OMoARcPSD| 28697339
I. Gas Exchange II. Infection
III. Acid-Base Balance
IV. Thermoregulation V. Clinical Judgment VI. Pain VII. Patient
Education VIII. Communication IX. Collaboration
Pneumonia-COPD
I. Data Collection
History of Present Problem:
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.
Personal/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?
RELEVANT Data from Present Problem: Clinical Significance:
Fever, difficulty breathing, no improvementThis is important because we need to look at the relevant data and
with the inhaler, productive cough of green realize that she seems to be in distress and first take care of that. Also
phlegm. realize that she seems to have an infection. With this information we
are able to prioritize
RELEVANT Data from Social History: Clinical Significance:
She was widowed 6 months ago after being This is important because when caring for her we need to keep in
married for 64 years, and she feels like it is mind her age, stressors in her life and any limitations the
beginning of the end for her.
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:
