Pneumonia-COPD Case Study: Clinical Reasoning and Patient Care, Exams of Business

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Comprehensive Care for

Pneumonia and COPD

Exacerbation

Pneumonia-COPD Case Study

Gas Exchange

The primary focus of this case study is the patient's impaired gas exchange due to the combination of community-acquired pneumonia and an acute exacerbation of chronic obstructive pulmonary disease (COPD). The patient's respiratory status is compromised, leading to hypoxemia and the potential for respiratory acidosis. Careful monitoring of the patient's oxygen saturation, respiratory rate, and arterial blood gas values is crucial to assess the severity of the gas exchange issues and guide appropriate interventions.

Infection

The patient has developed a community-acquired pneumonia, which has triggered an acute exacerbation of their underlying COPD. This dual pathology requires a comprehensive assessment of the patient's infectious status, including vital signs, sputum characteristics, and potential causative organisms. Appropriate antibiotic therapy, based on the suspected or confirmed pathogens, is essential to manage the infection and prevent further complications.

Acid-Base Balance

The impaired gas exchange and respiratory distress associated with the pneumonia and COPD exacerbation can lead to respiratory acidosis. Monitoring the patient's arterial blood gas values, particularly the pH, PaCO2, and HCO3-, is necessary to evaluate the acid-base status and guide interventions to maintain homeostasis.

Thermoregulation

The presence of pneumonia can contribute to alterations in the patient's body temperature, potentially leading to fever or hypothermia. Careful monitoring of the patient's temperature and appropriate management of any thermal dysregulation are important to support the patient's overall well- being.

Clinical Judgment

Effective clinical reasoning is crucial in this case study, as the nurse must synthesize the patient's history, current presentation, and diagnostic

findings to develop a comprehensive plan of care. The nurse must prioritize the patient's needs, implement appropriate interventions, and continuously evaluate the patient's response to guide further management.

Pain

The patient may experience discomfort or pain associated with the respiratory distress, coughing, and potential chest wall involvement due to the pneumonia and COPD exacerbation. Assessing the patient's pain level and implementing appropriate pain management strategies are essential to provide holistic care.

Patient Education

Educating the patient and their family about the nature of the patient's condition, the importance of adherence to the treatment plan, and strategies for managing the disease process in the long term are crucial components of the nursing care plan.

Communication

Effective communication with the patient, their family, and the interprofessional healthcare team is vital in this case study. The nurse must gather relevant information, coordinate care, and ensure that all stakeholders are informed and involved in the decision-making process.

Collaboration

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."

RELEVANT Data from Present Problem:

Clinical Significance: Fever, difficulty breathing, no improvement with the inhaler, and 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.

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?

| PMH | Home Meds | Pharm. Classification | Expected Outcome | | --- | --- | --- | --- | | COPD/asthma | 1. Fluticasone/salmeterol (Advair) diskus 1 puff every 12 hours

2. Albuterol (Ventolin) MDI 2 puffs every 4 hours prn | 1. Corticosteroid
3. Bronchodilator | 1. Improve breathing
4. Open up airway in the lungs | | Hypertension | 3. Lisinopril (Prinivil) 10 mg po daily | 3. ACE inhibitor | 3. Decrease blood pressure and open up blood vessels | | Hyperlipidemia | 4. Gemfribrozil (Lopid) 600 mg po bid | 4. Cholesterol | 4. Decrease fatty acids | | Anxiety disorder | 5. every 6 hours as needed | 5. Benzodiazepine | 5. Decrease anxiety and calm down | | 1ppd smoker x40 years. Quit 10 years ago | 6. Triamterene-HCTZ (Dyazide) 1 tab daily | 6. Potassium sparing diuretic | 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)

Patient Care Begins:

Current VS:

| Parameter | Current | Most Recent | | --- | --- | --- | | T | 103.2 (oral) | - | | P | 110 (regular) | - | | R | 30 (labored) | - | | BP | 178/96 | - | | O2 sat | 86% ( 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 | | Aggreviate | Shallow breathing | | Alleviate | Deep breath |

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

Clinical Significance: Temperature, pulse, respirations, blood pressure, O 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 it 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?

Clinical Significance: Her general appearance, respiratory, and cardiac assessments are important. Her general appearance indicates that she is having difficulty breathing and is anxious. Her respiratory assessment shows that she is in distress and having a possible asthma exacerbation. By listening, we can hear that she has some fluid on her lungs. Her cardiac assessment reveals 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 likely for this patient.

Clinical Reasoning Begins...

What is the primary problem that your patient is most likely presenting with? Pneumonia with COPD exacerbation and possible sepsis

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.

What nursing priority(s) will guide your plan of care? (if more than one-list in order of PRIORITY)

Breathing O BP HR

Temperature

What interventions will you initiate based on this priority?

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

Expected Outcome: - Increase O2 to at least 90% - Decrease her temperature - Decrease her BP

What body system(s) will you most thoroughly assess based on the primary/priority concern? Respiratory

What is the worst possible/most likely complication to anticipate? Sepsis or pneumothorax

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

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 | Rationale | Expected Outcome | | --- | --- | --- | | Albuterol-ipratropium (Combivent) 2.5 mg neb | Bronchodilator | Open up airway to increase O2 | | Establish peripheral IV | Access for medications | Have IV access | | Lorazepam (Ativan) 1 mg IV push | Help with anxiety | Decrease anxiety | | Methylprednisolone (Solumedrol) 125 mg IV push | Decrease bronchoconstriction | Increase oxygen going to lungs | | Levofloxacin (Levaquin) 750 mg IVPB (after blood cultures drawn) | Antibiotic | Decrease WBC and temp | | Acetaminophen (Tylenol) 1000mg oral | Decrease temperature | Decrease temp | | Chest x-ray (CXR) | Check the lungs to see what is going on | Pleural effusion | | Complete cell count (CBC) | Look at the electrolytes, BUN, Creat, glucose, etc. | Increase in WBC, RBC and lactate | | Basic metabolic panel (BMP) | Look at the electrolytes, BUN, Creat, glucose, etc. | Increase in glucose | | Lactate | Indicated hypoxia which leads to sepsis | | | Arterial blood gas (ABG) | Look at the electrolytes, BUN, Creat, glucose, etc. | Partially compensated respiratory acidosis | | Sputum culture with gram stain | Tell you if there is pneumonia | Positive | | Blood culture x2 sites | Tell you if the infection is in the blood | Positive | | Urine analysis (UA) | Check the urine for cells, protein, sugar or blood | Negative | | Urine culture (UC) | See if the infection is a UTI | Negative |

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

| Care Provider Orders | Order of Priority | Rationale | | --- | --- | --- | | 1. Albuterol-ipratropium (Combivent) 2.5 mg neb | 1 | Airway first r/t ABC's | |

2. Establish peripheral IV | 2 | Have access for medications | | 3. Lorazepam

(Ativan) 1 mg IV push | 3 | To help calm down and breathe easier | | 4. Methylprednisolone (Solumedrol) 125 mg IV push | 4 | Breathing is always one of the top priorities | | 5. Levofloxacin (Levaquin) 750 mg IVPB (after blood cultures drawn) | 5 | Start broad spectrum antibiotics to get in the system and help fight infection | | 6. Acetaminophen (Tylenol) 1000mg oral | 6 | - |

Medication Dosage Calculation:

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

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 insufficient, monitor I&O, weight patient daily. Possible sepsis

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: Photo toxicity, muscle weakness, and hepatic toxic

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

What lab results are RELEVANT that must be recognized as

clinically significant to the nurse?

Complete Blood Count (CBC)

| Parameter | Current | High/Low/WNL? | Most Recent | Trend: Improve/ Worsening/Stable | | --- | --- | --- | --- | --- | | WBC (4.5-11.0 mm 3) | 14.5 | High | 8.2 | Worsening | | Hgb (12-16 g/dL) | 13.3 | WNL | 12.8 | Stable | | Platelets (150-450x 103/μl) | 217 | WNL | 298 | Stable | | Neutrophil % (42-72) | 92 | High | 75 | Improving | | Band forms (3-5%) | 5 | WNL | 1 | Improving |

RELEVANT Lab(s): WBC, Neutrophil, Band forms Clinical Significance: Infection

Basic Metabolic Panel (BMP)

| Parameter | Current | High/Low/WNL? | Most Recent | Trend: Improve/ Worsening/Stable | | --- | --- | --- | --- | --- | | Sodium (135-145 mEq/L) | 138 | WNL | 142 | Stable | | Potassium (3.5-5.0 mEq/L) | 3.9 | WNL | 3.8 | Stable | | Chloride (95-105 mEq/L) | 98 | WNL | 96 | Stable | | CO2 (Bicarb) (21- mmol/L) | 35 | High | 31 | Improving | | Anion Gap (AG) (7-16 mEq/l) | 15 | WNL | 16 | Stable | | Glucose (70-110 mg/dL) | 112 | High | 102 | Improving | | Calcium (8.4-10.2 mg/dL) | 8.9 | WNL | 9.7 | Stable | | BUN (7 - 25 mg/dl) | 32 | High | 28 | Improving | | Creatinine (0.6-1.2 mg/dL) | 1.2 | WNL | 1.0 | Stable |

RELEVANT Lab(s): Bicarb, Glucose, BUN Clinical Significance: COPD, Prednisone, Renal, Sepsis

Misc. Labs

| Parameter | Current | High/Low/WNL? | Most Recent | Trend: Improve/ Worsening/Stable | | --- | --- | --- | --- | --- | | Lactate (0.5-2.2 mmol/L) | 3.2 | High | - | |

RELEVANT Lab(s): Lactate Clinical Significance: Indicated hypoxia which leads to sepsis

Arterial Blood Gas

| Parameter | Current | High/Low/WNL? | | --- | --- | --- | | pH (7.35-7.45) | 7. | Low | | pCO2 (35-45) | 68 | High | | pO2 (80-100) | 52 | Low | | HCO (18-26) | 36 | High | | O2 sat (>92%) | 84% | Low |

RELEVANT Lab(s): All of them Clinical Significance: Partially compensated respiratory acidosis

Urine Analysis (UA)

| Parameter | Current | High/Low

Clinical Significance

Vital Signs (VS)

The patient's vital signs are fine and improving. There is improvement in the patient's condition, and the nurse would still continue to monitor the vital signs.

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Respiratory Assessment

The patient has slight labored breathing and crackles. There is improvement in the patient's condition, and the nurse would continue the treatment and monitor how the patient does with weaning off oxygen.

Arterial Blood Gas (ABG) Results

The primary care provider decides to repeat the ABG, and the following results are obtained: - The nurse needs to evaluate whether the nursing priority or plan of care needs to be modified based on these ABG results.

Nursing Priorities and Plan of Care

Based on the current evaluation, the nursing priorities and plan of care may include: Administering more specific antibiotics Encouraging the patient to use an incentive spirometer

Handoff Report

As the patient is being transferred to the floor, the nurse provides an SBAR (Situation, Background, Assessment, Recommendation) report to the nurse who will be caring for the patient. The report includes the following information:

Situation

84-year-old female with possible pneumonia, COPD exacerbation, and possible sepsis

Background

Medical history: COPD, asthma, hypertension, heart failure, anxiety

Assessment

General Appearance: Resting comfortably, appears in no acute distress Respiratory: Breath sounds improved aeration bilaterally, coarse crackles with diminished aeration in the left lower lobe Cardiovascular: Pink, warm and dry, no edema, heart sounds regular with no abnormal beats, strong and equal pulses Neurological: Alert and oriented to person, place, time, and situation (x4) Gastrointestinal: Abdomen soft and non-tender, bowel sounds audible in all four quadrants Genitourinary: Voiding without difficulty, urine clear and yellow Skin: Skin integrity intact

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Recommendation

Continue the treatment plan, monitor vital signs, and schedule physical therapy.

Education Priorities and Discharge Planning

The most important discharge and education priorities to reinforce with the patient to prevent future readmission with the same problem include: Encouraging the patient to get up and move around Emphasizing the importance of hand washing

Providing education on coughing etiquette

Practical ways the nurse can assess the effectiveness of the teaching with this patient include:

Verifying that the patient verbalizes understanding of the provided education Observing the patient's demonstration of using the incentive spirometer

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