lOMoAR cPSD| 56342273
Pneumonia-COPD
, lOMoAR cPSD| 56342273
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 Judgment
5. Pain
6. Patient Education
7. Communication
8. Collaboration
UNFOLDING Reasoning Case Study: STUDENT
Pneumonia-COPD
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
persists. 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 night and has been using her albuterol inhaler every 1-2 hours with no improvement
so she called 9-1-1 and was 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 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, green phlegm x 4 Cough and phlegm can indicate pneumonia. Fever and chills are
days. Chills and fever of 102.0 F. s/sx of infection. Difficulty breathing can cause hypoxia and the
Dyspnea overnight. Administered inhaler client to panic. Use of inhaler with no improvement indicated
q 1-2 hrs with no improvement. further evaluation.
RELEVANT Data from Social History: Clinical Significance:
Pneumonia-COPD
, lOMoAR cPSD| 56342273
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 Judgment
5. Pain
6. Patient Education
7. Communication
8. Collaboration
UNFOLDING Reasoning Case Study: STUDENT
Pneumonia-COPD
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
persists. 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 night and has been using her albuterol inhaler every 1-2 hours with no improvement
so she called 9-1-1 and was 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 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, green phlegm x 4 Cough and phlegm can indicate pneumonia. Fever and chills are
days. Chills and fever of 102.0 F. s/sx of infection. Difficulty breathing can cause hypoxia and the
Dyspnea overnight. Administered inhaler client to panic. Use of inhaler with no improvement indicated
q 1-2 hrs with no improvement. further evaluation.
RELEVANT Data from Social History: Clinical Significance:
