Pneumonia/Chronic Obstructive Pulmonary Disease Clinical Reasoning Case Study. Complete Solution. A Graded.

Airway/Breathing (Oxygenation) Pneumonia/Chronic Obstructive Pulmonary Disease Clinical Reasoning Case Study STUDENT Worksheet 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. Concepts (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 I. Data Collection History 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. 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 improvement with the inhaler, productive cough of green phlegm. This is important because we need to look at the relevant data and realize that she seems to be in distress and first take care of that. Also 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 married for 64 years, and she feels like it is the beginning of the end for her. This is important because when caring for her we need to keep in mind her age, stressors in her life and any limitations 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: • COPD/asthma • Hypertension • Hyperlipidemia • Cor-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 2. bronchodilator 3. ACE inhibitor 4. cholesterol 5. benzodiazepine 6. potassium sparing diuretic 1. improve breathing 2. open up airway in the lungs 3. decrease blood pressure and open up blood vessels 4. decrease fatty acids 5. decrease anxiety and calm down 6. help body from not absorbing too much salt and keep potassium level from getting too low. One 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 their life? • Circle what PMH problem likely started FIRST • Underline what PMH problem(s) FOLLOWED as domino(s) 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? RELEVANT VS Data: Clinical Significance: Temperature, pulse, respirations, blood pressure, O2 sat, location of pain, and what aggravates and alleviates pain. The temperature is high which signifies infection. Pulse is also high which could be due to infection, fever or anxiety. Respriations are very high and O2 is very low this is a main concern, she is not getting enough oxygen into her system and can become hypoxic and go into resp acidocis. Blood pressure is elevated and she has a history of elevated BP and heart failure so it needs to be monitored. Patient is in pain and seem to be related to her lungs. 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? RELEVANT Assessment Data: Clinical Significance: General appearance, respiratory, and cardiac Her general appereance is important because we can see that she is having difficulty breathing and is anxious. Her respiratory assessment is important because again we can see that she is in distress and having a possible asthma exacerbation. Also by listening we can hear that she has some fluid on her lungs With her cardiac assessment we can see that she has a fever