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STUDENT-COPD-Pneumonia-FUNDAMENTAL_Reasoning.pdf

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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 Judgment 5. Pain

FUNDAMENTAL Reasoning: STUDENT Pneumonia-COPD

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

persists. 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 was 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 histories are RELEVANT and have clinical significance to the nurse?

RELEVANT Data from Present Problem: Clinical Significance:

RELEVANT Data from Social History: Clinical Significance:

Developing Nurse Thinking by Identifying Significance of Clinical Data Patient Care Begins:

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

RELEVANT VS Data: Clinical Significance:

Current VS: P-Q-R-S-T Pain Assessment (5th VS): 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% 6 liters n/c Timing: Intermittent–lasting a few seconds

What assessment data are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Assessment Data: Clinical Significance:

Developing Nurse Thinking through APPLICATION of the Sciences Fluid & Electrolytes/Lab/diagnostic Results:

Chest X-ray: What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT Results: Clinical Significance: Left lower lobe infiltrate.

Hypoventilation present

in both lung fields

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

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

RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

Current Assessment: GENERAL

APPEARANCE:

Appears anxious and in distress, barrel chest present

RESP: 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

Complete Blood Count (CBC) Current: High/Low/WNL? Prior:

WBC (4.5–11.0 mm 3) 14.5 8.2

Hgb (12–16 g/dL) 13.3 12.8

Platelets (150–450x 103/µl) 217 298

Neutrophil % (42–72) 92 75

Band forms (3–5%) 5 1

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s): Clinical Significance: TREND:

Improve/Worsening/Stable:

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s): Clinical Significance:

Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required:

WBC

Value:

14.5

Critical

value:

Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Prior:

Sodium (135–145 mEq/L) 138 142

Potassium (3.5–5.0 mEq/L) 3.9 3.8

CO2 (Bicarb) (21–31 mmol/L) 35 31

Glucose (70–110 mg/dL) 112 102

BUN (7–25 mg/dl) 32 28

Creatinine (0.6–1.2 mg/dL) 1.2 1.0

Misc. Labs: Current: Prior:

Lactate (0.5–2.2 mmol/L) 3.2 n/a

Arterial Blood Gas: Current: High/Low/WNL?

pH (7.35–7.45) 7.25

pCO2 (35–45) 68

pO2 (80–100) 52

HCO3 (18–26) 36

O2 sat (>92%) 84%

Lab: Normal Value: Why Relevant? Nursing Assessments/Interventions Required:

Lactate

Value:

3.2

Critical

Value:

Pharmacology: Home Med: Classification: Mechanism of Action

(in own words): Nursing Considerations:

Lorazepam

Atorvastatin

Enalapril

Albuterol

Metered dose

inhaler (MDI)

Salmeterol/flu

ticasone

diskus

Pathophysiology: 1. What is the primary problem that your patient is most likely presenting?

2. What is the underlying cause/pathophysiology of this primary problem?

Developing Nurse Thinking by Identifying Clinical RELATIONSHIPS 1. What is the RELATIONSHIP of the past medical history and current medications?

(Which medication treats which condition? Draw lines to connect)

PMH: Home Meds:

 COPD/asthma

 Hypertension

 Hyperlipidemia

 Cor-pulmonale

 Anxiety disorder

 1ppd smoker x40 years. Quit 10 years ago

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. Gemfribrozil (Lopid) 600 mg po bid

5. Diazepam (Valium) 2.5 mg po every 6 hours as needed

6. Triamterene-HCTZ (Dyazide) 1 tab daily

2. Is there a RELATIONSHIP between any disease in PMH that may have contributed to the development of the current problem? (Which disease likely developed FIRST that then began a “domino effect”?)

PMH: What Came FIRST:

 COPD/asthma

 Hypertension

 Hyperlipidemia

 Cor-pulmonale

 Anxiety disorder

 1ppd smoker x40 years. Quit 10 years ago

3. What is the RELATIONSHIP between the primary care provider’s orders and primary problem?

Care Provider Orders: How it Will Resolve Primary Problem/Nursing Priority:

Albuterol-ipratropium 2.5 mg neb

Establish peripheral IV

Lorazepam 1 mg IV push every 6 hours

prn anxiety

Methylprednisolone 125 mg IV push

Levofloxacin 750 mg IVPB (after blood

cultures drawn)

Acetaminophen 1000mg oral

Developing Nurse Thinking by Identifying Clinical PRIORITIES 1. Which Orders Do You Implement First and Why?

Care Provider Orders: Order of Priority: Rationale:

1. Albuterol-ipratropium 2.5 mg neb

2. Establish peripheral IV 3. Lorazepam 1 mg IV push 4. Methylprednisolone 125

mg IV push

5. Levofloxacin 750 mg IVPB (after blood cultures

drawn)

6. Acetaminophen 1000mg PO

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

3. What interventions will you initiate based on this priority?

Nursing Interventions: Rationale: Expected Outcome:

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

5. How can the nurse address these psychosocial needs?

6. What educational/discharge PRIORITIES will be needed to develop a teaching plan for this patient and/or family?

Caring & the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation?

2. What can I do to engage myself with this patient’s experience, and show that he/she matters to me as a person?

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.

1. What did I learn from this scenario?

2. How can I use what has been learned from this scenario to improve patient care in the future?

RELEVANT Data from Present ProblemRow1:
Clinical SignificanceRow1:
RELEVANT Data from Social HistoryRow1:
Clinical SignificanceRow1_2:
Current VS:
PQRST Pain Assessment 5th VS:
Deep breathShallow breathing:
P 110 regular:
Quality:
Ache:
R 30 labored:
BP 17896:
Severity:
310:
Timing:
Intermittentlasting a few seconds:
RELEVANT VS DataRow1:
Clinical SignificanceRow1_3:
Current Assessment:
GENERAL APPEARANCE:
Appears anxious and in distress barrel chest present:
RESP:
CARDIAC:
NEURO:
Alert oriented to person place time and situation x4:
GI:
GU:
Voiding without difficulty urine clearyellow:
SKIN:
Skin integrity intact skin turgor elastic no tenting present:
RELEVANT Assessment DataRow1:
Clinical SignificanceRow1_4:
Clinical SignificanceLeft lower lobe infiltrate Hypoventilation present in both lung fields:
Current:
Prior:
WBC 45110 mm 3:
HighLowWNL145:
82:
Hgb 1216 gdL:
HighLowWNL133:
128:
HighLowWNL217:
298:
Neutrophil 4272:
HighLowWNL92:
75:
Band forms 35:
HighLowWNL5:
1:
RELEVANT LabsRow1:
Clinical SignificanceRow1_5:
TREND ImproveWorseningStableRow1:
Current_2:
Prior_2:
HighLowWNL138:
142:
HighLowWNL39:
38:
HighLowWNL35:
31:
HighLowWNL112:
102:
BUN 725 mgdl:
HighLowWNL32:
28:
HighLowWNL12:
10:
Misc Labs:
HighLowWNLCurrent:
Prior_3:
HighLowWNL32_2:
na:
RELEVANT LabsRow1_2:
Clinical SignificanceRow1_6:
TREND ImproveWorseningStableRow1_2:
Arterial Blood Gas:
Current_3:
pH 735745:
HighLowWNL725:
pCO2 3545:
HighLowWNL68:
pO2 80100:
HighLowWNL52:
HCO3 1826:
HighLowWNL36:
O2 sat 92:
HighLowWNL84:
RELEVANT LabsRow1_3:
Clinical SignificanceRow1_7:
WBC Value 145:
Clinical SignificanceCritical value:
Nursing AssessmentsInterventions RequiredCritical value:
Lactate Value 32:
Why RelevantCritical Value:
Nursing AssessmentsInterventions RequiredCritical Value:
Home Med:
ClassificationLorazepam:
Mechanism of Action in own wordsLorazepam:
Nursing ConsiderationsLorazepam:
ClassificationAtorvastatin:
Mechanism of Action in own wordsAtorvastatin:
Nursing ConsiderationsAtorvastatin:
ClassificationEnalapril:
Mechanism of Action in own wordsEnalapril:
Nursing ConsiderationsEnalapril:
ClassificationAlbuterol Metered dose inhaler MDI:
Mechanism of Action in own wordsAlbuterol Metered dose inhaler MDI:
Nursing ConsiderationsAlbuterol Metered dose inhaler MDI:
ClassificationSalmeterolflu ticasone diskus:
Mechanism of Action in own wordsSalmeterolflu ticasone diskus:
Nursing ConsiderationsSalmeterolflu ticasone diskus:
PMH:
Home Meds:
PMH_2:
What Came FIRSTCOPDasthma Hypertension Hyperlipidemia Corpulmonale Anxiety disorder 1ppd smoker x40 years Quit 10 years ago:
Care Provider Orders:
How it Will Resolve Primary ProblemNursing PriorityAlbuterolipratropium 25 mg neb Establish peripheral IV Lorazepam 1 mg IV push every 6 hours prn anxiety Methylprednisolone 125 mg IV push Levofloxacin 750 mg IVPB after blood cultures drawn Acetaminophen 1000mg oral:
Order of Priority1Albuterolipratropium 25 mg neb 2Establish peripheral IV 3Lorazepam 1 mg IV push 4Methylprednisolone 125 mg IV push 5Levofloxacin 750 mg IVPB after blood cultures drawn 6Acetaminophen 1000mg PO:
Rationale1Albuterolipratropium 25 mg neb 2Establish peripheral IV 3Lorazepam 1 mg IV push 4Methylprednisolone 125 mg IV push 5Levofloxacin 750 mg IVPB after blood cultures drawn 6Acetaminophen 1000mg PO:
Nursing InterventionsRow1:
RationaleRow1:
Expected OutcomeRow1:
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