CASE STUDY WEEK 10 JOANN WALKER, 84 YEARS OLD PNEUMONIA/CHRONIC OBSTRUCTIVE PULMONARY DI, Lab Reports of Nursing

Download CASE STUDY WEEK 10 JOANN WALKER, 84 YEARS OLD PNEUMONIA/CHRONIC OBSTRUCTIVE PULMONARY DI and more Lab Reports Nursing in PDF only on Docsity! lOMoARcPSD|28697339 CASE STUDY WEEK 10 JOANN WALKER, 84 YEARS OLD PNEUMONIA/CHRONIC OBSTRUCTIVE PULMONARY DISEASE CLINICAL REASONING CASE STUDY AIRWAY/BREATHING (OXYGENATION) PNEUMONIA/CHRONIC OBSTRUCTIVE PULMONARY DISEASE CLINICAL REASONING CASE STUDY 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. STUDENT Worksheet JoAnn Walker, 84 years old lOMoARcPSD|28697339 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 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: • COP D / a st h m a 1. Fluticasone/salmeterol 1. corticosteroid 1. improve breathing • Hypertension (Advair) diskus 1 puff every 2. bronchodilator 2. open up airway in the lungs • Hyperlipidemia 12 hours 3. ACE inhibitor 3. decrease blood pressure and • Cor-pulmonale 2. Albuterol (Ventolin) MDI 4. cholesterol open up blood vessels • Anxiety disorder 2 puffs every 4 hours prn 5. benzodiazepine 4. decrease fatty acids • 1ppd smoker x40 years. 3. Lisinopril (Prinivil) 10 mg 6. potassium sparing diuretic 5. decrease anxiety and calm Quit 10 years ago po daily down 4. Gemfribrozil (Lopid) 600 6. help body from not mg po bid absorbing too much salt and 5. Diazepam (Valium) 2.5 keep potassium level from mg po every 6 hours as getting too low. needed 6. Triamterene-HCTZ lOMoARcPSD|28697339 5. What body system(s) will you most thoroughly assess based on the primary/priority concern? Respiratory 6. What is the worst possible/most likely complication to anticipate?Sepsis or pneumothorax 7. 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 8. 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 ( . What interventions will you initiate based on this priority? 4 Nursing Interventions: Rationale: Expected Outcome: Increase oxygen (8-10 L on mask or nonrebreather). Place on a cooling blanket. Inform doctor of BP. 6 L was not enough because he 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. Increase O2 to at least %. 90 decrease her temperature. decrease her BP. Care Provider Orders: Rationale: Expected Outcome: albuterol-ipratropium ( Combivent) 2.5 mg neb Establish peripheral IV Lorazepam (Ativan) 1 mg IV push Methylprednisolone ( Solumedrol) 125 mg IV push Levofloxacin (Levaquin) 750 mg IVPB (after blood cultures drawn) Acetaminophen (Tylenol) 1000 mg oral Chest x-ray (CXR) Complete cell count (CBC) Basic metabolic panel 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. 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 lOMoARcPSD|28697339 stain PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale: 1. Albuterol-ipratropium 1. 1 (Combivent) 2.5 mg neb 2. Establish peripheral IV 2. 2 3. Lorazepam (Ativan) 1 mg IV push 3. 3 4. Methylprednisolone (Solumedrol) 125 mg IV 4. 4 push 5. Levofloxacin (Levaquin) 5. 5 750 mg IVPB (after blood cultures drawn) 6. 6 6. Acetaminophen (Tylenol) 1000mg oral Medication Dosage Calculation: 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. BMP) Lactate Arterial blood gas (ABG) Sputum culture with gram Blood culture x2 sites Urine analysis (UA) Urine culture (UC) Possible sepsis Tell you if there is pneumonia Tell you if the infection is in the blood Check the urine for cells, protein, sugar or blood See if the infection is a UTI Increase in lactate Decrease ph, co2, respiratory acidosis. Positive Positive Negative Negative Volume/time frame to Mechanism of Action: Medication/Dose: Safely Administer: Nursing Assessment/Considerations: lorazepam Ativan ) ( 1 mg IV push Normal Range: Average Depress CNS by GABA IV Push: Volume every 15 sec? minutes 2-5 Fall risk, possible addiction, monitor respirations. Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: methylprednisolone ( Solumedrol ) 125 mg IV push Normal Range: high Corticosteroid decreases inflammation of the bronchial IV Push: Volume every 15 sec? None Adrenal insufficient, monitor I&O, weight patient daily. lOMoARcPSD|28697339 6. won’t act as fast so you can do last. Radiology Reports: What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse? Lab Results: What lab results are RELEVANT that must be recognized as clinically significant to the nurse? Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: levofloxacin ( Levaquin ) 750 mg IVPB Normal Range: average Broad spectrum antibiotic 150 mL over 90 minutes Hourly rate on pump: 100 ml/hr Photo toxicity, muscle weakness, and hepatic toxic. RELEVANT Results: Clinical Significance: Left lower lobe infiltrate. Hypoventilation present in both lung fields Buildup of fluid, bacterial infection. Hypoventilation- COPD lOMoARcPSD|28697339 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: Lab: Normal value: Why Relevant? Nursing Assessments/Interventions Required: Lactate Value: 3.2 0.5- 2.2 Critical Value: Over 2.2 Indicated hypoxia which leads to spesis Hospital sepsis protocol, monitor temp, HR, and BP lOMoARcPSD|28697339 Situation: 84 year old female who has possible pneumonia with COPD exacerbation and possible sepsis Background: COPD, asthma, HTN, heart failure, anxiety Assessment: GENERALAPPEARANCE: 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: lOMoARcPSD|28697339 You report your assessment findings to the primary care provider who decides to repeat the ABG. You obtain 3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? Yes 4. Based on your current evaluation, what are your nursing priorities and plan of care?More specific antibiotics, have 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: Continue treatment plan, monitor vitals, and schedule PT. the following results: Arterial Blood Gas: Current: Most Recent: pH (7.35-7.45) 7.31 7.25 55 pCO2 (35-45) 68 pO2 (80-100) 78 52 HCO3 (18-26) 35 36 O2 sat (>92%) 91 % 84 % 2 . Has the status improved or not as expected to this point? Improved