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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
Pneumonia-COPD
I. Data Collection
History of Present Problem:

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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 improvement This 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:
 COPD/asthma 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
(Dyazide) 1 tab daily
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)
II. Patient Care Begins:

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Current VS: WILDA Pain Scale (5th VS):

T: 103.2 (oral) Words: Ache
P: 110 (regular) Intensity: 3/10
R: 30 (labored) Location: Generalized over right side of chest with no radiation
BP: 178/96 Duration: Intermittent-lasting a few seconds
O2 sat: 86% Aggreviate: Deep breath
6 liters n/c Alleviate: Shallow breathing
What VS data is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT VS Data: Clinical Significance:
Temperature, pulse, The temperature is high which signifies infection. Pulse is also high which could be
respirations, blood due to infection, fever or anxiety. Respriations are very high and O2 is very low this is a
pressure, O2 sat, location main concern, she is not getting enough oxygen into her system and can become
of pain, and what hypoxic and go into resp acidocis. Blood pressure is elevated and she has a history of
aggravates and alleviates elevated BP and heart failure so it needs to be monitored. Patient is in pain and seem to
pain. be related to her lungs.

Current Assessment:
GENERAL Appears anxious and in distress
APPEARANCE:
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: Clinical Significance:
General appearance, respiratory, and Her general appereance is important because we can see that she is
cardiac 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

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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 all 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 piss 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

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

Nursing Interventions: Rationale: Expected Outcome:
Increase oxygen (8-10 L on mask or 6L was not enough because he sat was only Increase O2 to at least
nonrebreather). 86%. 90%.
Place on a cooling blanket. To decrease the temperature without having decrease her
Inform doctor of BP. to give too much medication for it. temperature.
To see if they want to give any medication decrease her BP.
for it.

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

Care Provider Orders: Rationale: Expected Outcome:
albuterol-ipratropium Bronchodilator. Open up airway to increase O2.
(Combivent) 2.5 mg neb
Access for medications. Have IV access
Establish peripheral IV
Help with anxiety. Decrease anxiety
Lorazepam (Ativan) 1 mg IV
push
Decrease bronchoconstriction. Increase oxygen going to lungs.
Methylprednisolone
(Solumedrol) 125 mg IV Antibiotic. Decrease WBC and temp
push
Decrease temperature. Decrease temp
Levofloxacin (Levaquin) 750
mg IVPB (after blood cultures Check the lungs to see what is going on. Pleural effusion
drawn)
Help detect if there is an infection going on. Increase in WBC, RBC and
Acetaminophen (Tylenol)
lactate
1000mg oral
Look at the electrolytes, BUN, Creat, glucose, etc.
Chest x-ray (CXR) Increase in glucose

Complete cell count (CBC)

Basic metabolic panel

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(BMP) Increase in lactate

Possible sepsis
Lactate Tell you if there is pneumonia Decrease ph, co2,
respiratory acidosis.
Arterial blood gas (ABG) Tell you if the infection is in the blood
Positive
Sputum culture with gram Check the urine for cells, protein, sugar or blood
stain Positive
See if the infection is a UTI
Blood culture x2 sites Negative

Urine analysis (UA)

Negative

Urine culture (UC)

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

Care Provider Orders: Order of Priority: Rationale:
1. Albuterol-ipratropium 1. 1 1. airway first r/t ABC’s
(Combivent) 2.5 mg neb
2. Establish peripheral IV 2. 2 2. have access for medications
3. Lorazepam (Ativan) 1 mg
IV push 3. 3 3. to help calm down and breathe easier
4. Methylprednisolone
(Solumedrol) 125 mg IV 4. 4 4. breathing is always one of the top priorities
push
5. Levofloxacin (Levaquin) 5. 5 5. start broad spectrum antibiotics to get in the system and
750 mg IVPB (after blood help fight infection.
cultures drawn) 6. 6
6. Acetaminophen (Tylenol) 6. won’t act as fast so you can do last.
1000mg oral

Medication Dosage Calculation:

Medication/Dose: Mechanism of Action: Volume/time frame to Nursing Assessment/Considerations:
Safely Administer:
lorazepam Depress CNS by GABA Fall risk, possible addiction, monitor
(Ativan) respirations.
1 mg IV push IV Push: Volume every 15
sec?
Normal Range: 2-5 minutes
Average

Medication/Dose: Mechanism of Action: Volume/time frame to Nursing Assessment/Considerations:

Safely Administer:
methylprednisolone Corticosteroid decreases Adrenal insufficient, monitor I&O,
(Solumedrol) inflammation of the weight patient daily.
125 mg IV push bronchial IV Push: Volume every
15 sec?
Normal Range: None
high

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Medication/Dose: Mechanism of Action: Volume/time frame to Nursing Assessment/Considerations:

Safely Administer:
levofloxacin Broad spectrum antibiotic 150 mL over 90 Photo toxicity, muscle weakness, and
(Levaquin) minutes hepatic toxic.
750 mg IVPB

Normal Range: Hourly rate on pump:

average 100ml/hr

Radiology Reports:
What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Results: Clinical Significance:
Left lower lobe infiltrate. Buildup of fluid, bacterial infection. Hypoventilation- COPD
Hypoventilation present
in both lung fields

Lab Results:
What lab results are RELEVANT that must be recognized as clinically significant to the nurse?
Complete Blood Count (CBC:) Current: High/Low/WNL? Most Recent:
WBC (4.5-11.0 mm 3) 14.5 High 8.2
Hgb (12-16 g/dL) 13.3 WNL 12.8
Platelets(150-450x 103/µl) 217 WNL 298
Neutrophil % (42-72) 92 High 75
Band forms (3-5%) 5 WNL 1

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:
WBC Infection WBC increasing
Neutrophil Neutrophil increasing
Band forms Band forms improving

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

Sodium (135-145 mEq/L) 138 WNL 142
Potassium (3.5-5.0 mEq/L) 3.9 WNL 3.8
Chloride (95-105 mEq/L) 98 WNL 96
CO2 (Bicarb) (21-31 mmol/L) 35 High 31
Anion Gap (AG) (7-16 mEq/l) 15 WNL 16
Glucose (70-110 mg/dL) 112 High 102
Calcium (8.4-10.2 mg/dL) 8.9 WNL 9.7
BUN (7 - 25 mg/dl) 32 High 28
Creatinine (0.6-1.2 mg/dL) 1.2 WNL 1.0
Misc. Labs: Current High/Low/WNL? Most Recent
Lactate (0.5-2.2 mmol/L) 3.2 High

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

Bicarb COPD Increasing
Glucose Prednisone Increasing
BUN Renal Increasing
Lactate Sepsis N/A

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

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): Clinical Significance: TREND: Improve/Worsening/Stable:

All of them Partially compensated respiratory acidosis N/A

Urine Analysis (UA:) Current: High/Low/WNL?

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): Clinical Significance: TREND: Improve/Worsening/Stable:

Bacteria They are OK since it is few N/A
Epithelial

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

Lab: Normal value: Why Relevant? Nursing Assessments/Interventions Required:
Lactate 0.5- 2.2 Indicated hypoxia Hospital sepsis protocol, monitor temp, HR, and BP
which leads to spesis
Value:
Critical Value:
3.2
Over 2.2

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: Most Recent:

T: 100.8 (oral) T: 103.2 (oral)
P: 88 (regular) P: 110 (regular)
R: 24 (slight labored) R: 30 (labored)
BP: 128/90 BP: 178/96
O2 sat: 92% O2 sat: 86%
4 liters n/c 6 liters n/c

Current
Assessment:
GENERAL Resting comfortably, appears in no acute distress
APPEARANCE:
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: Clinical Significance:
VS are fine and improving There is improvement, I would still continue to monitor vital signs

RELEVANT Assessment Data: Clinical Significance:

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

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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: Most Recent:
pH (7.35-7.45) 7.31 7.25
pCO2 (35-45) 55 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

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:

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

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