NR 341 Pneumonia-COPD Case Study Solutions

11 July 2024

Pneumonia-COPD Case Study Solutions

Medical Surgical (Jersey College Nursing School)

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:

JoAnn Walker is an 84-year-old female who has had a productive cough of green phlegm for 4 days 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 arrived 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 into the room when the pastor asked Joan if she would like to pray. The patient said, “Yes, this may be 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:

  • 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:

  • 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?

PMH:

  • COPD/asthma
  • Hypertension
  • Hyperlipidemia
  • Cor-pulmonale
  • Anxiety disorder
  • 1ppd smoker x40 years. Quit 10 years ago

Home Meds:

  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. Gemfibrozil (Lopid) 600 mg po bid
  5. Diazepam (Valium) 2.5 mg po every 6 hours as needed
  6. Triamterene-HCTZ (Dyazide) 1 tab daily

Pharm. Classification:

  1. corticosteroid
  2. bronchodilator
  3. ACE inhibitor
  4. cholesterol
  5. benzodiazepine
  6. potassium-sparing diuretic

Expected Outcome:

  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.

II. Patient Care Begins:

Current VS:

  • T: 103.2 (oral)
  • P: 110 (regular)
  • R: 30 (labored)
  • BP: 178/96
  • O2 sat: 86% on 6 liters n/c

WILDA Pain Scale (5th VS):

  • Words: Ache
  • Intensity: 3/10
  • Location: Generalized over right side of chest with no radiation
  • Duration: Intermittent-lasting a few seconds
  • Aggravate: Deep breath
  • Alleviate: Shallow breathing

What VS data is RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT VS Data:

  • 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. Respirations are very high, and O2 is very low; this is a main concern as she is not getting enough oxygen into her system and can become hypoxic and go into respiratory acidosis. Blood pressure is elevated, and she has a history of elevated BP and heart failure, so it needs to be monitored. The patient is in pain and seems 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:

  • General appearance, respiratory, and cardiac
  • Her general appearance 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.

12 Lead EKG:

  • Interpretation: Sinus tachycardia

Clinical Significance:

  • Tachycardia can be due to many possible explanations such as infection, anxiety, or fever. All of which are very likely for this patient.

III. Clinical Reasoning Begins…

  1. What is the primary problem that your patient is most likely presenting with?
    • Pneumonia with COPD exacerbation and possible sepsis
  2. What is the underlying cause/pathophysiology of this problem?
    • Pneumonia is an infection in which the lungs contain fluid or pus caused by many different things such as bacteria, fungi, parasites, and more.
  3. What nursing priority(s) will guide your plan of care? (if more than one-list in order of PRIORITY)
    • Breathing, O2, BP, HR, temperature
  4. What interventions will you initiate based on this priority?

Nursing Interventions:

  • Increase oxygen (8-10 L on mask or nonrebreather).
  • Place on a cooling blanket.
  • Inform doctor of BP.

Rationale:

  • 6L was not enough because her sat was only 86%.
  • To decrease the temperature without having to give too much medication for it.
  • To see if they want to give any medication for it.

Expected Outcome:

  • Increase O2 to at least 90%.
  • Decrease her temperature.
  • Decrease her BP.
  1. What body system(s) will you most thoroughly assess based on the primary/priority concern?
    • Respiratory
  2. What is the worst possible/most likely complication to anticipate?
    • Sepsis or pneumothorax
  3. What nursing assessment(s) will you need to initiate to identify this complication if it develops?
    • Sepsis: Temp, HR, BP, lactic acid
    • Pneumothorax: SOB, CP
  4. What nursing interventions will you initiate if this complication develops?
    • Sepsis: follow hospital procedure
    • Pneumothorax: call DR and prepare to insert a chest tube (this is emergent)

Medical Management: Rationale for Treatment & Expected Outcomes

Care Provider Orders:

  1. Albuterol-ipratropium (Combivent) 2.5 mg neb
  2. Establish peripheral IV
  3. Lorazepam (Ativan) 1 mg IV push
  4. Methylprednisolone (Solumedrol) 125 mg IV push
  5. Levofloxacin (Levaquin) 750 mg IVPB (after blood cultures drawn)
  6. Acetaminophen (Tylenol) 1000 mg oral
  7. Chest x-ray (CXR)
  8. Complete cell count (CBC)
  9. Basic metabolic panel (BMP)
  10. Lactate
  11. Arterial blood gas (ABG)
  12. Sputum culture with gram stain
  13. Blood culture x2 sites
  14. Urine analysis (UA)
  15. Urine culture (UC)

Rationale:

  • Bronchodilator.
  • Access for medications.
  • Help with anxiety.
  • Decrease bronchoconstriction.
  • Antibiotic.
  • Decrease temperature.
  • Check the lungs to see what is going on.
  • Help detect if there is an infection going on.
  • Look at the electrolytes, BUN, Creat, glucose, etc.

Expected Outcome:

  • Open up airway to increase O2.
  • Have IV access.
  • Decrease anxiety.
  • Increase oxygen going to lungs.
  • Decrease WBC and temp.
  • Decrease temp.
  • Pleural effusion.
  • Increase in WBC, RBC, and lactate.
  • Increase in glucose.

PRIORITY Setting: Which Orders Do You Implement First and Why?

Care Provider Orders:

  1. Albuterol-ipratropium (Combivent) 2.5 mg neb
  2. Establish peripheral IV
  3. Lorazepam (Ativan) 1 mg IV push
  4. Methylprednisolone (Solumedrol) 125 mg IV push
  5. Levofloxacin (Levaquin) 750 mg IVPB (after blood cultures drawn)
  6. Acetaminophen (Tylenol) 1000 mg oral

Order of Priority:

  1. 1
  2. 2
  3. 3
  4. 4
  5. 5
  6. 6

Rationale:

  1. airway first r/t ABC’s
  2. have access for medications
  3. to help calm down and breathe easier
  4. breathing is always one of the top priorities
  5. start broad-spectrum antibiotics to get in the system and help fight infection.
  6. won’t act as fast so you can do last.

Medication Dosage Calculation:

Medication/Dose:

  • Lorazepam (Ativan) 1 mg IV push

Mechanism of Action:

  • Depress CNS by GABA

Volume/time frame to Safely Administer:

  • IV Push: Volume every 15 sec? 2-5 minutes

Nursing Assessment/Considerations:

  • Fall risk, possible addiction, monitor respirations.

Medication/Dose:

  • Methylprednisolone (Solumedrol) 125 mg IV push

Mechanism of Action:

  • Corticosteroid decreases inflammation of the bronchial

Volume/time frame to Safely Administer:

  • IV Push: Volume every 15 sec? None

Nursing Assessment/Considerations:

  • Adrenal insufficiency, monitor I&O, weight patient daily.

Medication/Dose:

  • Levofloxacin (Levaquin) 750 mg IVPB

Mechanism of Action:

  • Broad-spectrum antibiotic

Volume/time frame to Safely Administer:

  • 150 mL over 90 minutes. Hourly rate on pump: 100ml/hr

Nursing Assessment/Considerations:

  • Phototoxicity, muscle weakness, and hepatic toxicity.

Radiology Reports:

What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT Results:

  • Left lower lobe infiltrate.
  • Hypoventilation present in both lung fields

Clinical Significance:

  • Buildup of fluid, bacterial infection. Hypoventilation- COPD

Lab Results:

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

Complete Blood Count (CBC:)

Current:

  • WBC (4.5-11.0 mm³): 14.5 High
  • Hgb (12-16 g/dL): 13.3 WNL
  • Platelets (150-450x 10³/µl): 217 WNL
  • Neutrophil % (42-72): 92 High
  • Band forms (3-5%): 5 WNL

Most Recent:

  • WBC: 8.2
  • Hgb: 12.8
  • Platelets: 298
  • Neutrophil %: 75
  • Band forms: 1

RELEVANT Lab(s):

  • WBC
  • Neutrophil
  • Band forms

Clinical Significance:

  • Infection

TREND:

  • WBC increasing
  • Neutrophil increasing
  • Band forms improving

Basic Metabolic Panel (BMP:)

Current:

  • Sodium (135-145 mEq/L): 138 WNL
  • Potassium (3.5-5.0 mEq/L): 3.9 WNL
  • Chloride (95-105 mEq/L): 98 WNL
  • CO₂ (Bicarb) (21-31 mmol/L): 35 High
  • Anion Gap (AG) (7-16 mEq/l): 15 WNL
  • Glucose (70-110 mg/dL): 112 High
  • Calcium (8.4-10.2 mg/dL): 8.9 WNL
  • BUN (7-25 mg/dl): 32 High
  • Creatinine (0.6-1.2 mg/dL): 1.2 WNL

Most Recent:

  • Sodium: 142
  • Potassium: 3.8
  • Chloride: 96
  • CO₂: 31
  • Anion Gap: 16
  • Glucose: 102
  • Calcium: 9.7
  • BUN: 28
  • Creatinine: 1.0

Misc. Labs:

Current High/Low/WNL?

  • Lactate (0.5-2.2 mmol/L): 3.2 High

RELEVANT Lab(s):

  • Bicarb
  • Glucose
  • BUN
  • Lactate

Clinical Significance:

  • COPD
  • Prednisone
  • Renal
  • Sepsis

TREND:

  • Increasing
  • Increasing
  • Increasing
  • N/A

Arterial Blood Gas:

Current:

  • pH (7.35-7.45): 7.25 Low
  • pCO₂ (35-45): 68 High
  • pO₂ (80-100): 52 Low
  • HCO₃ (18-26): 36 High
  • O₂ sat (>92%): 84% low

RELEVANT Lab(s):

  • All of them

Clinical Significance:

  • Partially compensated respiratory acidosis

TREND:

  • N/A

Urine Analysis (UA:)

Current:

  • Color (yellow): Yellow WNL
  • Clarity (clear): Clear WNL
  • Specific Gravity (1.015-1.030): 1.015 WNL
  • Protein (neg): Neg WNL
  • Glucose (neg): Neg WNL
  • Ketones (neg): Neg WNL
  • Bilirubin (neg): Neg WNL
  • Blood (neg): Neg WNL
  • Nitrite (neg): Neg WNL
  • LET (Leukocyte Esterase) (neg): Neg WNL

MICRO:

  • RBC’s (<5): 1 WNL
  • WBC’s (<5): 3 WNL
  • Bacteria (neg): Few High
  • Epithelial (neg): Few high

RELEVANT Lab(s):

  • Bacteria
  • Epithelial

Clinical Significance:

  • They are OK since it is few

TREND:

  • N/A

Lab Planning: Creating a Plan of Care with a PRIORITY Lab:

Lab:

  • Lactate

Value:

  • 3.2

Normal value:

  • 0.5-2.2

Critical Value:

  • Over 2.2

Why Relevant?

  • Indicated hypoxia which leads to sepsis

Nursing Assessments/Interventions Required:

  • Hospital sepsis protocol, monitor temp, HR, and BP

IV. Evaluation:

One hour later…

You have been able to implement all orders and it has been 30 minutes since the nebulizer treatment. Your collect the following clinical reassessment data:

Current VS:

  • T: 100.8 (oral)
  • P: 88 (regular)
  • R: 24 (slight labored)
  • BP: 128/90
  • O2 sat: 92% on 4 liters n/c

Most Recent:

  • T: 103.2 (oral)
  • P: 110 (regular)
  • R: 30 (labored)
  • BP: 178/96
  • O2 sat: 86% on 6 liters n/c

Current Assessment:

GENERAL APPEARANCE:

  • Resting comfortably, appears in no acute distress

RESP:

  • Breath sounds improved aeration bilaterally, coarse crackles with diminished aeration in left lower lobe (LLL)

CARDIAC:

  • Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, 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
  1. What clinical data is RELEVANT that must be recognized as clinically significant?

RELEVANT VS Data:

  • VS are fine and improving
  • There is improvement; I would still continue to monitor vital signs

RELEVANT Assessment Data:

  • Slight labored breathing and crackles
  • There is improvement in the patient’s condition; I would continue treatment, see how she does with weaning of O2

You report your assessment findings to the primary care provider who decides to repeat the ABG. You obtain the following results:

Arterial Blood Gas:

Current:

  • pH (7.35-7.45): 7.31
  • pCO₂ (35-45): 55
  • pO₂ (80-100): 78
  • HCO₃ (18-26): 35
  • O₂ sat (>92%): 91%

Most Recent:

  • pH: 7.25
  • pCO₂: 68
  • pO₂: 52
  • HCO₃: 36
  • O₂ sat: 84%
  1. Has the status improved or not as expected to this point?
    • Improved
  2. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
    • Yes
  3. Based on your current evaluation, what are your nursing priorities and plan of care?
    • More specific antibiotics, have the patient use an incentive spirometer.

It is now time to transfer your patient to the floor. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient:

Situation:

  • 84-year-old female who has possible pneumonia with COPD exacerbation and possible sepsis

Background:

  • COPD, asthma, HTN, heart failure, anxiety

Assessment:

  • GENERAL APPEARANCE: Resting comfortably, appears in no acute distress
  • RESP: Breath sounds improved aeration bilaterally, coarse crackles with diminished aeration in left lower lobe (LLL)
  • CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, 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

Recommendation:

  • Continue treatment plan, monitor vitals, and schedule PT.

V. Education Priorities/Discharge Planning

  1. What will be the most important discharge/education priorities you will reinforce with their medical condition to prevent future readmission with the same problem?
    • Get up and moving, wash hands, coughing etiquette
  2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?
    • Verbalizes understanding, demonstrates incentive spirometer usage.

VI. Caring and the “Art” of Nursing

  1. What is the patient likely experiencing/feeling right now in this situation?
    • Relief, now that she can breathe again
  2. What can you do to engage yourself with this patient’s experience, and show that he/she matter to you as a person?
    • Give the patient your time and attention, listen, smile, use touch