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Unit 5 Ticket to Class COPD Pneumonia Case Study Sp22

Student
chronic nursing care (Clatsop Community College)

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Student: Leah Durham

NRS 111 Unit 5 Ticket to Class Spring 2022

The ticket to class for Unit 5 is provided below. Submit your responses to the Unit 5
electronic drop box on Brightspace by 10am on May 3rd.Bring your answers with
.you (printed or electronic version) and be prepared to discuss them during class

RAPID Reasoning COPD- Pneumonia

Joan Walker, 84 years old
Primary Concept:
Gas Exchange
:Interrelated Concepts (in order of importance)
Infection .1
Acid-Base Balance .2
Thermoregulation .3
Clinical Judgment .4
Pain .5

COPD- Pneumonia
History of Present Problem: Joan Walker is an 84-year-old female with a history of
chronic obstructive pulmonary disease (COPD); she 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 night and has been using her albuterol inhaler 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 the beginning of the end for me
What data from the patient problems are RELEVANT and must be interpreted as
?clinically significant by the nurse
RELEVANT data from Present Problem Clinical Significance

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Cough with green phlegm and not getting better
with meds, fibril, difficulty breathing with no
improvement with use of inhaler
May be the start of a lung infection such as
pneumonia, fever from infection, difficulty
breathing could be from possible infection in the
lungs and worsening COPD plus if the patient is
anxious, this could cause the difficulty breathing
as well.

RELEVANT data from Social History Clinical Significance

Primary support is no longer with her. She has her

Widowed within the last 6 months, loves in pastor as support, but the patient is experiencing
assisted living, expressed fear of passing. fear and anxiety of passing and thinks she might
not make it out of the hospital.

:Patient Care Begins

Current VS: P-Q-R-S-T Pain
Assessment
T: 103.2 F/39.6 C (oral) Provoking/Palliative Deep breath/Shallow breathing
P: 110 (regular) Quality: Ache
R: 30 (labored) Region/Radiation: Generalized over right side of chest with no
radiation
BP: 178/96 Severity: 3/10
O2 sat: 86% on 6 liters Timing: Intermittent-lasting a few seconds
per nasal cannula

What VS data are RELEVANT and must be recognized as clinically significant to the
?nurse

:RELEVANT VS data :Clinical Significance

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T: 103.2 (H) Fever R/T infection, most likely in the lungs. Increased HR due to
P: 110 (H) fever, infection, and anxiety. Priority concern is increased
RR: 30 (H) respirations with low O2 due to deep and shallow breaths.
O2: 86% on 6L NC (L) Patient’s blood pressure is also elevated which may be due to the
BP: 178/96 fever and anxiety. Patient does have a history of high blood
Respirations are deep and pressure so monitoring should be continued.
shallow, with an ache over the
right side of the chest.

Current
PHYSICAL
Assessment
General Appearance Appears anxious and in distress, barrel chest present.
RESPIRATORY Dyspnea with use of accessory muscles, breath sounds very
diminished bilaterally ant/post 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, skin turgor elastic, no tenting present.

What ASSESSMENT data are RELEVANT and must be recognized as clinically

RELEVANT ASSESSMENT data:
Anxious and in distress
Barrel chest present
Dyspnea and use of accessory
muscles
?significant to the nurse
Clinical Significance:
Being visibly anxious can cause her breathing to worsen, and have
trouble breathing
The barrel chest indicates later stages of COPD with the chest
being overinflated.
R/T COPD exacerbation

Breath sounds diminished R/T fluid build-up causing the wheezing sound on exhale.
bilaterally on ant/post with
scattered expiratory wheezing

Pale, hot, and dry heart Indicative of fever

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Student: Leah Durham

?What is the clinical significance of the radiologic report provided below

Radiology Report: Clinical Significance:

Chest X-Ray (frontal and lateral Patient has pneumonia. The patient is not getting enough air and
views): left lower lobe infiltrate. her oxygen is decreased and her carbon dioxide is increased in
Hypoventilation present in both the blood. This could be due to COPD exacerbation.
lung fields.

Lab Results
Complete Blood Count Current High/Low/Normal Prior results
Value
WBC (4.5–11.0 mm 3) 14.5
High 8.2

Hgb (12-16 g/dL) 13.3

WNL 12.8

Platelets (150-450 x103/µl) 217

WNL 298

Neutrophil % (42–72) 92
High 75

Band forms (3-5) 5

WNL 1

Basic Metabolic Panel: Current High/Low/Normal Prior results

Value
Sodium (135–145 mEq/L) 138 WNL 142
Potassium (3.5–5.0 mEq/L) 3.9 WNL 3.8
CO2 [Bicarb] (21-31 mmol/L) 35 High 31
Glucose (70–110 mg/dL) 112 High 102
BUN (7-25 mg/dL) 32 High 28
Creatinine (0.6–1.2 mg/dL) 1.2 WNL 1.0
Miscellaneous Labs Current High/Low/Normal Prior results
Value
Lactate (0.5-2.2 mmol/L) 3.2 High N/A
Blood cultures (neg) pending N/A

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Student: Leah Durham

What lab results are RELEVANT and must be recognized as clinically significant by the
?nurse
RELEVANT Labs Clinical Significance:
CO2 High CO2 levels indicate the body isn’t releasing enough carbon
Glucose dioxide. Slightly increased BG can be from the prednisone
BUN prescribed. BUN can be from the kidneys not working properly,
Lactate dehydration, or from heart failure. High lactate can be from heart
Sodium failure or sepsis. Sodium is WNL but it is decreasing so it should
Creatinine be monitored for the continuing trend. Creatinine should also be
watched since it is the high end of normal.

Arterial Blood Gas Current High/Low/Normal

Value
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

?What ABG results are RELEVANT and must be recognized as clinically significant by the nurse
RELEVANT Labs Clinical Significance:
pH Patient is in respiratory acidosis and partially compensating.
pCO2
pO2
HCO3, O2

Urine Analysis (UA) Current High/Low/Normal

Clean catch specimen Value
Color (yellow) Yellow WNL
Clarity (clear) Clear WNL

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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
Leucocyte Esterase (neg) Neg WNL
MICRO Analysis
RBCs (<5) 1 WNL
WBCs (<5) 3 WNL
Bacteria (neg) Few High
Epithelial cells (neg) Few High

?What UA results are RELEVANT and must be recognized as clinically significant by the nurse
RELEVANT Labs Clinical Significance:
Bacteria Patient might have not cleaned properly before voiding. Should
Epithelia be watched in case of an increase.

…Clinical Reasoning Begins

.1 Describe the underlying cause/pathophysiology of this chronic obstructive pulmonary disease
. (COPD)

:Pathophysiology of COPD
A condition of chronic dyspnea with expiratory airflow limitation that does not significantly
fluctuate. This is caused by airway inflammation, mucous plugging. Narrowed airway lumina,
.or airway destruction

.2 Collaborative Care: Medical Management

Care Provider Orders Rationale Expected Outcome
albuterol-ipratropium 2.5 mg Bronchodilator to open Improve breathing
nebulizer now then every 4 airways
hours
establish peripheral IV Administer medications and Aid in a potential emergency
fluids if needed situation and to help with
dehydration
lorazepam 1 mg IV push every Decrease anxiety Pt becomes less anxious

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6 hours prn anxiety

methylprednisolone 40 mg IV Decrease inflammation Improve breathing
push every 12 hours
levofloxacin 750 mg IVPB Treat a variety of bacterial Treat infection
every 24 hours infections including
pneumonia
acetaminophen 1000 mg Decrease temperature and No fever or pain
orally x 1 dose relieve pain

Collaborative Care: Nursing

.3 What nursing priority (ies) will guide your plan of care? Write four (4) nursing diagnoses for this
. patient below; place them in order of priority

,Impaired Gas Exchange R/T Ineffective Airway clearance AEB copious mucus

Ineffective Airway Clearance R/T shortness of breath AEB RR of 30, O2 of 88% on 6L of O2 NC

Risk for Infection R/T chronic disease process
Anxiety R/T unknown outcomes AEB pt statements regarding feeling anxious
Risk for loneliness R/T lack of support system

.4 What psychosocial needs will this patient and/or family likely have that will need to be
?addressed

.The patient will need emotional support and comfort. She will need help in controlling her anxiety

?How can the nurse address these psychosocial needs.5

Taking the time to sit and listen to her concerns will probably go a long way in helping meet here
.psychosocial needs and medical needs

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Caring and the “Art” of Nursing

?What is the patient likely experiencing/feeling right now in this situation .1

The pt is probably feeling very confused and anxious and terrified of the unknown.
She was taken out of the only place she has support and thinks she will never
.return

What can you do to engage yourself with this patient’s experience and show that she matters to you .2
?as a person

Taking the time to have a cup of coffee while she eats breakfast or using
.therapeutic communication techniques to let her know we care

.Use Reflection to THINK Like a Nurse

Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the

patient’s response to an intervention in the moment as the events are unfolding
.to make a correct clinical judgment
?What did I learn from this scenario .1

I learned how to better put myself in the shoes of a patient who had an exacerbation of COPD. I learned
. what the treatment would look like and how to better give nursing care to a patient with COPD

?How can I use what has been learned from this scenario to improve patient care in the future .2
I can think back to this case study and be familiar with the drugs, signs and symptoms, and patient’s
.feelings in order to give the best nursing care I can

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