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67 y.

o
Caucasian
Male
ADMITTED THROUGH THE ED
WITH DYSPNEA AND COUGH

Medical History
▪ Coronary artery disease

▪ Bacteremia

▪ Hypertrophic obstructive
cardiomyopathy

▪ Hypertension

▪ Chronic kidney disease

▪ Parkinson’s disease

▪ Hyperlipidemia

▪ Psoriasis

▪ Obstructive sleep apnea

▪ Psoriatic arthritis

▪ Atelectasis and respiratory
insufficiency

▪ Diabetes

▪ Bipolar
▪ Endocarditis

▪ Peripheral neuropathy

Medical data
▪ The patient does not have an
official admitting diagnosis.
▪ However, the plan of care is
empiric treatment for Pneumonia.
▪ The patient has no previous
history of Pneumonia. He does
have a history of respiratory
insufficiency and has obstructive
sleep apnea.

Pathophysiology

(Ignatavicius, Workman, 2013, pg.
647)

▪ Pneumonia is a build up of fluids in a lung(s)
from an inflammatory process.
▪ The inflammation can be triggered by
bacteria, viruses or something irritating that
has been inhaled.
▪ An organism will infiltrate the mucosa of the
airway and seek to multiply in the alveoli.
▪ WBC’s will travel to the infection site which
then causes the capillaries to leak, edema and
produce exudate.
▪ The fluids will collect and the alveoli wall will
thicken.
▪ This will reduce the exchange of gases and
cause hypoxia.

Bacteria
infiltrates
lung
mucosa
Reduced
gas
exchange
and
hypoxemia

This fluid
build up
causes
alveoli
walls to
thicken

WBC’s
travel to
the site of
infection

This
causes
capillaries
to leak,
edema and
exudate

Diagnostic & Lab data
▪ Cl 108 ↑ <Cardiac decompensation, Kidney
dysfunction>
▪ BUN 21 ↑ <Kidney damage, dehydration>
▪ Alb 2.4 ↓ <Renal disorders, prolonged immobility,
malnutrition>
▪ Hgb 11.5 ↓ <Kidney diseases, Anemia>

CXR
showing
normal
lungs

▪ Hct 33.6 ↓ <Chronic kidney failure, Anemia>
▪ Plt 132 ↓ <Zithromax>
▪ PT 15.9 ↑ <Heart failure, Warfarin>
▪ BNP 115 ↑ <Heart failure, left ventricular
hypertrophy, myocarditis, renal failure>
▪ eGFR 67 ↓ <Chronic kidney disease>
▪ CXR shows possible atelectasis and PNA. Doctors
want to rule out PNA clinically.

CXR
showing
Pneumoni
a

Physical
Assessmen
t

Nursing Assessment
Respiratory
▪ RR: 19, labored
▪ Lung Fields
▪ Wheezing present in all fields
during expiration
▪ Diminished lung sounds in right
lower lung field

▪ O2 Sat: 95% on RA
▪ O2 ordered PRN

▪ Unproductive cough

Nursing Assessment
Circulation
▪ BP: 118/74
▪ HR: 79, strong & regular
▪ Edema: +2 pitting in BL LE
▪ Pedal Pulses: Palpable, but weak
on right foot
▪ Capillary refill: 3-seconds
▪ Mucous membranes: Moist, pink
▪ Telemetry: Sinus rhythm (SR)

Nursing Assessment
Neurologic
▪ A&O x3
▪ Poor historian
▪ Wife in room to answer health
hx questions

▪ Limited sensation (&
weakness) in BL LE
▪ PERRLA

Nursing Assessment
Integumentary
▪ Pink in color; cool to touch
▪ Dry with scaling from psoriasis
▪ More extensive on BL feet

▪ Braden Score: 12
▪ High Risk

▪ Stage 1 gluteal cleft decubitus ulcer
▪ IV: Left AC 20g NS @ 125 mL/hr
▪ Dressing dry & intact with tape &
transparent dressing
▪ No signs of redness or swelling, cool to
touch

Nursing Assessment
Elimination
▪ Urinary incontinence
▪ Incontinent briefs: 2-3 with
minimal output in each
▪ BM: 4-days ago
▪ Normally 1x/day

▪ Bowel sounds: Active, all
four quadrants
▪ Abdomen: Firm upon
palpation

Nursing Assessment
Nutrition
▪ More than body requires
▪ Unintentional wt. gain

▪ Ht.: 5’9”
▪ Wt.: 250#
▪ BMI: 36.9
▪ Increased abdominal adiposity
▪ Diet: ADA

Nursing Assessment
Mobility
▪ Limited ROM
▪ Unsteady gait & balance
▪ Peripheral neuropathy

▪ Strength: BL weak, upper &
lower
▪ Hand grip
▪ Leg muscles

▪ Assistive Devices
▪ Wheelchair

Nursing Assessment
Activity & Self-Care
▪ Dependent
▪ Toileting
▪ Bathing
▪ Dressing
▪ Walking (wheelchair bound)
▪ Stairs
▪ Laundry
▪ Shopping
▪ Housecleaning

▪ Partial Assist
▪ Feeding
▪ Medications

Nursing Assessment
Comfort & Rest
▪ Pain: 3-4 level
▪ Location: Low back (since
admission)
▪ Quality: Ache

▪ Sleep patter: 8-10 hr/day
▪ Evening nap

▪ No sleeping concerns

Nursing Assessment
Psychosocial & Spiritual
▪ Diminished communicative
cognition since 2013 (per wife)
▪ “Can I slap your bottom?”

▪ Presents with diminished
problem solving & abstract
reasoning
▪ Responds in two to three words at
a time.
▪ Short attention span/distracts
easily.

Nursing Assessment
Miscellaneous
▪ Safety & Security
▪ Wife is support system

▪ Loving & Belonging
▪ Spouse

▪ Self-Esteem
▪ Ego Integrity vs. Despair

Medication
s

The Data

The Study
▪ “With the MR30 strain, all the
treatments increased the rate
of sterile blood cultures with
respect to the controls…”
▪ “The high dose of vancomycin
was better than the low dose
(100% versus 64.3%).”
▪ “With MR33, linezolid and high
dose vancomycin increased the
sterile blood cultures compared
with the controls (93.3% and
100% versus 40%)…”

VS.
▪ “The high dose was superior to
the low dose of vancomycin
(100% versus 66.7%).”
▪ “Although the treatment
duration chosen for the model
is shorter than the time
required to treat pneumonia in
the clinical setting, 72 hours is
sufficient to observe significant
differences in the bacterial
burden in lungs related to the
antimicrobial treatments.”
J. Antimicrob. Chemother. (2012) 67 (8): 1961-1967.

Medication PRN
▪ Acetaminophen (Tylenol)- 650mg - Analgesic
▪ Bisacodyl Suppository (Dulcolax) – 10mg – Constipation
▪ Dextrose 50% (D50W) – 25ml – Hypoglycemia
▪ Glucagon (human recombinant) – 1mg – Hypoglycemia
▪ Insulin Lispro (Humalog) – 0-4U – Diabetes Mellitus
▪ Ondansetron (Zofran-ODT) – 4mg – Anti-emetic
▪ Polyethylene Glycol (Glycolax) – 17g - Constipation

Scheduled medications
▪ Albuterol (Proventil) – 2.5mg – Bronchodilator
▪ Aripiprazole (Abilify) – 2.5mg – Bipolar/Depression
▪ Aspirin – 81mg – Prophylactic for Myocardial Infarction
▪ Atrovastatin (Lipitor) – 20mg – Hypercholesterolemia
▪ Azithromycin (Zithromax) – 500mg – Anti-infective
▪ Carbidopa-levodopa (Sinemet CR) – 1 tablets – AntiParkinson
▪ Carbidopa-levodopa (Sinemet) – 2 tablets – AntiParkinson
▪ Cefepime (Maxipime) - 1g – Anti-Infective

Scheduled Medications (cont.)
▪ Cetirizine (Zyrtec) – 10mg - Antihystimine
▪ Choldcalciferol (Vitamin D3) – 2,000U – Supplement
▪ Cyanocobalamin (Vitamin B12) – 1,000U – Supplement
▪ Donepezil (Aricept) - 10mg – Cognitive Function
▪ Duloxetine (Cymbalta) – 60mg – Peripheral Neuropathy
▪ Enoxaparin (Lovenox) – 1mg/kg - Prophylactic DVT
▪ Ferrous Sulfate – 325mg – Iron deficiency anemia
▪ Folic Acid (Folvite) – 1mg – Folic acid deficiency

Scheduled Medications (cont.)
▪ Insulin Detemir (Levemir) – 20U - Diabetes Mellitus
▪ Ipratropium-Albuterol (Duo-Neb) – 3ml – Bronchodilator
▪ Lisinopril (Prinivil, Zestril) – 2.5mg – Antihypertensive
▪ Metoprolol (Lopressor) – 50mg – Antihypertensive
▪ Multivitamin (Theragran) – 1 tablet – Supplement
▪ Ondansetron (Zofran-ODT) – 4mg – Anti-emetic
▪ Topiramate (Topamax) – 50mg – Bipolar

Scheduled Medications (cont.)
▪ Tramadol (Ultram) – 100mg – Analgesic
▪ Vancomycin (Vancocin) – 1,250mg – Antibiotic
▪ Warfarin (Coumadin) – 2mg – Anticoagulant
▪ Warfarin (Coumadin) – 1mg – Anticoagulant

Therapeutic
procedures
• DRUG THERAPY
• Antibiotics
• RESPIRATORY ASSESSMENT
• ORAL CARE
• RT
• Ipratropium-Albuterol nebulizer q4
• CPAP at night when sleeping
• PT
• OT
• *REST ARE IN NS INTERVENTIONS*

THE IMPORTANCE OF ORAL HYGEINE IN
PREVENTING PNEUMONIA IN THE
HOSPITALIZED PATIENT
i.

Deterioration of oral health in
hospitalized patients puts him/her
at risk for a HAI that could possibly
lead to PNA.

ii. Studies show that dental plaque
houses bacteria that have been the
causative agent in patient’s who
have healthcare acquired
pneumonia.
iii. Proper, routine oral care for
hospitalized patient’s have reduced
the incidence of healthcare
acquired pneumonia.
(Quinn et al. 2014, pg. 13)

#1. Decreased cardiac output RT altered
contractility AEB cough, dyspnea, weak
peripheral pulses, edema in lower
extremities, weight gain, decreased urine
output and change in mental status.
Goal: Patient will have decreased edema to +1 or better within 24 - 48 hours.
Interventions: Monitor I&O & daily weights
Apply SCD’s and compression stockings to lower extremities
Check blood pressure before administering cardiac medications
Monitor edema using the +1 to +4 scale.
Evaluation: Patient’s output is much less than his input and it hasn’t changed.
Edema in the lower extremities is still at +2. BP was within normal limits before
giving cardiac medicines. Continuing to monitor pt. The doctor has been notified.

#2. Excess fluid volume RT cardiac
dysfunction and renal failure AEB edema +2
in lower extremities and pt low urine output.
Goal: Patient will maintain urine output of >60ml/hr within 2 days.
Interventions: Provide a restricted sodium diet as ordered and ensure adequate
protein intake.
Monitor electrolyte levels closely
Monitor patient’s behavior for restlessness, anxiety or confusion, use safety
precautions is symptoms are present.
Evaluation: Patient is on a heart healthy diet and is eating under 2g of sodium a
day and is eating protein with every meal. Electrolytes are within accepted range
except for Cl-, which is slightly elevated. Blood to be drawn again in the AM for a
CMP.

#3. Ineffective breathing pattern RT loss of
functional lung tissue & obesity AEB CXR
shows visible atelectasis and patient grunts
Goal:on
Patient
will maintain an effective
breathing
while breathing and wheezing
expiration.
pattern AEB normal RR and depth with absence of dyspnea & wheezing within 24
hours.
Interventions: Administer O2 as needed
Monitor RR, ease and depth of respirations
Note use of accessory muscles, nasal flaring, retraction, irritability confusion or
lethargy
Auscultate breath sounds & ensure RT gives patient his breathing treatment q4
Monitor pulse oximetry & keep patient bed elevated
Educate the patient on pursed lip breathing and controlled breathing techniques.
Evaluation: Patient has not needed O2 as his levels have been above 95%. He is
slightly short of breath but it seems to be more from his obesity at this point in
time but his RR are within normal limits. He is still grunting when breathing so I
asked him to take a few deep breaths and cough a few times to help open alveoli.
Wheezing on expiration was diminished after RT treatment.

 Impaired physical mobility RT high BMI, peripheral neuropathy,
neuromuscular impairment and sedentary lifestyle.
 Impaired skin integrity RT mechanical factors, physical
immobilization AEB stage 1 pressure ulcer on tail bone,
psoriasis dry patches throughout body (mostly on feet) and
slow skin healing due to diabetes.
 Activity intolerance RT immobility and sedentary lifestyle AEB
patient needs assistance with 95% of self-tasks, can’t move his
own legs, can barely use his arms with minimal strength and
he needed four people to move him onto a stretcher to be
taken down for tests.
 Impaired walking RT obesity, neuromuscular impairment AEB
patient unable to move legs on his own and he was unable to
feel me move his legs.
 Impaired urinary elimination RT urinary obstruction AEB
incontinence.
 Impaired verbal communication RT alteration in the central
nervous system AEB difficulty forming sentences, inappropriate
verbalization, and difficulty in comprehending usual
communication pattern.
 Acute pain RT lack of movement in bed, and uncomfortable
bed AEB patient reports a pain of 3 or 4 in his lower back that
started after he got to the hospital.
 Impaired comfort RT patient’s inability to move in bed due to
obesity AEB inability to relax, tense, drowsy from lack of
comfort and reports being uncomfortable.
 Interrupted family processes RT modification in family finances

Nursing
diagnoses

Health
promotion,
Cultural &
Development
al
consideration
s.

American Culture
▪ American culture has been prone to many
illnesses such as obesity due to poor food choices.
Such as fast, greasy and processed food, this has
contributed to chronic diseases in the elderly.
Patient has developed hyperlipidemia, diabetes,
obstructive sleep apnea, and CAD which could be
the result of his obesity.
▪ Patient weights 250lbs and his height is 5’9”.
▪ Patient is on a heart healthy diet and is eating
under 2g of sodium a day and is eating protein in
every meal.
▪ He has limited mobility due to obesity, and
peripheral neuropathy.
▪ Patient’s obesity has contributed to his respiratory
problems.

Health promotion
▪ Obesity is a major public health problem in the United
States, and it’s the cause of major complications in the
cardiovascular and respiratory system. Obesity has been
associated with a 36% increase in health care spending,
and treating the obese patient can be medically
challenging (Obesity- Health issue).
▪ Obesity is defined as body mass index of 30 or above.
▪ The patient’s BMI is 36.9 due to his sedentary lifestyle,
he is obese and he needs assistance with at least 95%
of his ADLs. The patient also has difficulty breathing due
to his weight.

Developmental Considerations
▪ 67 year old Male, Caucasian
▪ Erickson Stage: Ego Integrity vs. despair. The work of this stage is to
accept one’s life as meaningful.
▪ As we grow older change is more prevalent and chronic illness becomes
more critical. Excess weight can also cause degeneration of the
musculoskeletal system, especially the joints.
▪ Obese people are also more susceptible to infections and infectious
diseases tend to heal more slowly.
▪ Patient is at risk for constipation due to insufficient physical activity.
▪ Patient has impaired skin integrity related to physical immobilization.

Health Promotion
•Suggests an initial exercise program
that consist of a short 10 min/day,
which gradually increases to 30
minutes/day.
•Planning food intake for each day
•Self-monitoring of food intake,
including keeping a food and exercise
diary.
•Controlling stimuli that cause
overeating, such as watching

Common complications R/T
obesity.
•Type 2 diabetes mellitus
•Hypertension
•Hyperlipidemia
•Coronary Artery Disease
(CAD)
•Stroke
•Peripheral artery disease
(PAD)
•Obstructive Sleep apnea
•Obesity hypoventilation
syndrome
•Metabolic syndrome
•Depression and other
mental health/behavioral
health problems
•Urinary incontinence

Coordination of Care
▪ Occupational Therapy
▪ Supporting health and well-being
▪ Empowering individuals
▪ Promote quality of life

▪ Respiratory Therapy
▪ Breathing Treatment

Occupational Therapy
▪ ADL’s

▪ Home modifications to
promote activity
participation

▪ Progressive Increase in
Activity Tolerance

▪ Planning for healthier
choices (Food Selection)

▪ Safe household and
community mobility

▪ Relaxation and Sleep
routines

▪ Body Mechanics for
activities and transfers

▪ Coping with pain, stress and
anxiety within a social
context

▪ Monitoring and Managing
Skin Integrity

▪ Sexual Health (expression,
communication, positioning

Patient Teaching
▪ Repositioning in Bed (Pressure ulcers, Low back pain and
lung fluid)
▪ SCD’s and Compression stockings
▪ Nutrition
▪ Importance of Water

▪ Including client’s significant other
in teaching. Focus on five key
points of cardiac discharge
teaching
▪ Daily weight monitoring
▪ Symptom recognition
▪ Heart Healthy Eating
▪ Medication and adherence to regimen
▪ Routine check-ups

Discharge
Planning/
Patient Teaching
Decreased cardiac output RT altered
contractility AEB cough, dyspnea,
weak peripheral pulses, edema in
lower extremities, weight gain,
decreased urine output and change
in mental status

▪ Daily weight monitoring and
reporting
▪ Fluid and sodium restriction. Help
plan schedule with client and family
for fluid intake. Refer to dietitian for
low-sodium diet.
▪ Teach how to monitor intake and
output.

Discharge
Planning/
Patient Teaching
Excess fluid volume RT cardiac
dysfunction and renal failure AEB
edema +2 in lower extremities and
pt low urine output.

▪ Pursed-lip breathing (improves
respiratory function)
▪ Progressive relaxation (during
episodes of dyspnea)
▪ Consult Occupational Therapy for
energy conservation techniques

Discharge
Planning/
Patient Teaching
Ineffective breathing pattern RT loss
of functional lung tissue AEB CXR
shows visible atelectasis and pt
grunts while breathing.

Using Your “Noggin”

▪ A 67 y.o. obese pt. with a hx of DM, HTN, and CRF has
+2 pitting edema in his BL lower extremities and
wheezing in all lobes. The HCP has written an order to
administer a loop and thiazide diuretic. Which of the pt.
lab values would the prudent nurse want to look at first?
▪ A.
▪ B.
▪ C.
▪ D.

References
Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care (10th ed., p. 178; 185; 373). Maryland
Heights, Mo., Missouri: Mosby.
Docobo-Pérez, F., López-Rojas, R., Domínguez-Herrera, J., Jiménez-Mejias, M. E., Pichardo, C., Ibáñez-Martínez, J., & Pachón, J. (2012).
Efficacy
of linezolid versus a pharmacodynamically optimized vancomycin therapy in an experimental pneumonia model caused by methicillinresistant Staphylococcus aureus. Journal Of Antimicrobial Chemotherapy (JAC), 67(8), 1961-1967.
Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care (7th ed., p. 647). St. Louis, Mo.: Elsevier.
Kent, V.P. (2011). Put a cap on community-acquired pneumonia. Nursing made incredibly easy!, 9(2), 34-44.
Patterson, C.M. & Loebinger, M.R. (2012). Community acquired pneumonia: assessment and treatment. Clinical Medicine, 12(3), 283-6.
Pizzi, M. A. (2013). Obesity, Health and Quality of Life: A Conversation to Further the Vision in Occupational Therapy. Occupational Therapy In
Health Care, 27(2), 78-83. doi:10.3109/07380577.2013.778442
Quinn, B., Baker, D. L., Cohen, S., Stewart, J. L., Lima, C. A., & Parise, C. (2014). Basic Nursing Care to Prevent Non-ventilator Hospital-Acquired
Pneumonia. Journal Of Nursing Scholarship, 46(1), 11-19. doi:10.1111/jnu.12050
Ward-Smith, P.(2010). Obesity—America’s Health Crisis. Urologic Nursing, 30(4), 242-245. Retrieved April 18, 2015, from health source:
Nursing/Academic Edition.