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:
Productive cough of green phlegm four Productive cough is a clinical manifestation.
days ago that persists. Sputum in shades of
yellow- green indicates bacterial infection.
Started three days ago on prednisone 60
mg PO daily and azithromycin 250 mg This respiratory infection was treated by an
PO x5 days by her clinic physician. antibiotic and steroids.
Fever last night of 102.0 Nurse determine if treatment was effective,
Response to bacterial infection. Inflammatory
More difficulty breathing during the response.
night and has been using her albuterol
inhaler every 1-2 hours with no Recurrent pneumonia is a common
improvement 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 Joan values spirituality. Spirituality is
arrived and came back with the patient. important to patient and the nurse must be
The nurse walked in the room when the sensitive
pastor asked Joan if she would like to
pray. Emotional support will be a priority for
disease
The patient said, ―Yes, this may the
beginning of the end for me!‖
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:
Productive cough of green phlegm four Productive cough is a clinical manifestation.
days ago that persists. Sputum in shades of
yellow- green indicates bacterial infection.
Started three days ago on prednisone 60
mg PO daily and azithromycin 250 mg This respiratory infection was treated by an
PO x5 days by her clinic physician. antibiotic and steroids.
Fever last night of 102.0 Nurse determine if treatment was effective,
Response to bacterial infection. Inflammatory
More difficulty breathing during the response.
night and has been using her albuterol
inhaler every 1-2 hours with no Recurrent pneumonia is a common
improvement 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 Joan values spirituality. Spirituality is
arrived and came back with the patient. important to patient and the nurse must be
The nurse walked in the room when the sensitive
pastor asked Joan if she would like to
pray. Emotional support will be a priority for
disease
The patient said, ―Yes, this may the
beginning of the end for me!‖
