Pneumonia-COPD

© 2016 Keith Rischer/www.KeithRN.com

 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
6. Patient Education
7. Communication
8. Collaboration

UNFOLDING Reasoning Case Study: 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 is RELEVANT and 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.
phlegm. Also 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.

© 2016 Keith Rischer/www.KeithRN.com

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 diskus 1 puff every 12 2. bronchodilator 2. open up airway in the
• Hyperlipidemia hours 2. Albuterol MDI 2 3. ACE inhibitor lungs
• Cor-pulmonale puffs every 4 hours prn 4. cholesterol 3. decrease blood pressure
• Anxiety 3. Lisinopril 10 mg PO daily 5. benzodiazepine and
• 1ppd smoker x40 years; 4. Gemfibrozil 600 mg PO 6. potassium sparing open up blood vessels
quit 10 years ago bid diuretic 4. decrease fatty acids
5. Diazepam 2.5 mg PO 5. decrease anxiety and
every 6 hours as needed 6. calm
Triamterene-HCTZ 1 tab down
PO daily 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 created a “domino effect” in her life?
 Circle what PMH problem likely started FIRST

 Underline what PMH problem(s) FOLLOWED as domino(s)

Patient Care Begins:

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 VS data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
Temperature, pulse, The temperature is high which signifies infection. Pulse is also high which could be due to
respirations, blood infection, fever or anxiety. Respirations are very high and O2 is very low this is a main
pressure, O2 sat, concern, she is not getting enough oxygen into her system and can become hypoxic and go
location into resp acidosis. Blood pressure is elevated, and she has a history of elevated BP and
of pain, and what heart failure so it needs to be monitored. Patient is in pain and seem to be related to her
aggravates and lungs.
alleviates
pain.

© 2016 Keith Rischer/www.KeithRN.com

Current Assessment:
GENERAL Appears anxious and in distress, barrel chest present
APPEARANCE:
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

What assessment data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data: Clinical Significance:
Her general appearance is important because we can see that she is having
General appearance, respiratory, and difficulty breathing and is anxious. Her respiratory assessment is important
cardiac 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

12 Lead EKG

© 2016 Keith Rischer/www.KeithRN.com

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.

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. Crackles and fluid in the lungs
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? Previous:

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:

© 2016 Keith Rischer/www.KeithRN.com

 Infection WBC increasing
WBC Neutrophils Increasing
Neutrophils Band forms improving
Band forms

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

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
Misc. Labs:
Lactate (0.5–2.2 mmol/L) 3.2 High n/a

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
COPD Increasing
Bicarb Prednisone Increasing
Glucose Renal Increasing
BUN Sepsis N/A
Lactate

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

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance:
All Partially compensated Respiratory acidosis

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

© 2016 Keith Rischer/www.KeithRN.com

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
RBCs (<5) 1 WNL
WBCs (<5) 3 WNL
Bacteria (neg) Few High
Epithelial (neg) Few High
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:
Okay since its only a few N/A
Bacteria
Epithelial

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 Indicates hypoxia Hospital sepsis protocol

Value: Critical Value:

Over 2.2
3.2

Clinical Reasoning Begins…

1. What is the primary problem that your patient is most likely presenting with?
a COPD with infection

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

a Fluid in lungs, high temp, infection.

Collaborative Care: Medical Management

Care Provider Orders: Rationale: Expected Outcome:
Albuterol-ipratropium 2.5 1. Bronchodilator Open airway first
mg neb 2. Access for meds Have IV access
3. Help with anxiety Decrease anxiety
4. Antibiotic Decrease temp
© 2016 Keith Rischer/www.KeithRN.com
Establish peripheral IV 5. Decrease temp
6.

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

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

Care Provider Orders: Order of Priority: Rationale:
1.Albuterol-ipratropium 2.5 7. Albuterol Airways first
mg neb 8. Peripheral IV IV access for meds
2.Establish peripheral IV 9. Lorazepam Help calm down patient
3.Lorazepam 1 mg IV push 10. Methylprednisolone Breathing is always a high priority
4.Methylprednisolone 125 11. Levofloxacin Broad spectrum antibiotic first
mg IV push Acetaminophen Wont act fast so you can do last
5.Levofloxacin 750 mg
IVPB (after blood cultures
drawn)
6.Acetaminophen 1000mg
PO

Collaborative Care: Nursing

3. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY)
a Opening airway, bringing down patients temp, identifying infection

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

Nursing Interventions: Rationale: Expected Outcome:
Airway first ABC’s first Opened airway
Decrease temp Lower symptoms of infection Lowered temp
Identify infection to treat it Treat infection Treatment for
infection

© 2016 Keith Rischer/www.KeithRN.com

5. What body system(s) will you most thoroughly assess based on the primary/priority concern?
a Lungs

6. What is the worst possible/most likely complication to anticipate?

a Loses airway

7. What nursing assessments will identify this complication EARLY if it develops?

a ABC’s assessment

8. What nursing interventions will you initiate if this complication develops?

a Contact provider and respiratory therapist

9. What psychosocial needs will this patient and/or family likely have that will need to be addressed?
a Anxiety and confusion

10. How can the nurse address these psychosocial needs?

a Calm patient down by explaining what is happening and what the patient will need to do during these
procedures

Medication Dosage Calculation:

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

© 2016 Keith Rischer/www.KeithRN.com

 Lorazepam Depresses CNS Fall risk, possible addiction,
respirations
1 mg IV push IV Push:
(2 mg/1 mL vial) Volume every 15 sec? 2-5
mins

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

Safely Administer: Assessment/Considerations:
Methylprednisolone Corticosteroid decreases Adrenal insufficiency, monitor I’s
inflammation and O’s, weight patient daily
125 mg IV push IV Push:
(125 mg/2 mL vial) Volume every 15 sec?
None

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

Safely Administer:
levofloxacin
Broad spectrum Phototoxic, muscle weakness,
750 mg IVPB antibiotic Hourly rate IVPB: hepatotoxic
(150 mL volume) 100mL/Hr

Evaluation: One
hour later…
You have been able to implement all orders and it has been 30 minutes since the last nebulizer treatment. Your collect
the following clinical reassessment data:
Current VS: Most Recent: Current PQRST:
T: 100.8 F/38.2 C (oral) T: 103.2 F/39.6 C (oral) Provoking/Palliative:
P: 88 (regular) P: 110 (regular) Quality: Denies pain
R: 24 (slight labored) R: 30 (labored) Region/Radiation:
BP: 128/90 BP: 178/96 Severity:
O2 sat: 92% 4 liters n/c O2 sat: 86% 6 liters n/c Timing:

Current
Assessment:
GENERAL Resting quietly, appears in no acute distress
APPEARANCE:
RESP: Breath sounds improved aeration bilaterally, coarse crackles with diminished aeration in left
lower lobe (LLL)
© 2016 Keith Rischer/www.KeithRN.com
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:
Improvement, continue to monitor
VS steadily improving

RELEVANT Assessment Data: Clinical Significance:

Improvement in the patient’s condition, continue treatment, trial with
weaning off O2
Slight labored breathing/crackles

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: Prior:
pH (7.35–7.45) 7.31 7.25
pCO2 (35–45) 55 68
pO2 (8–-100) 78 52
HCO3 (18–26) 35 36
O2 sat (>92%) 91% 84%
What ABG results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance:
pH Basic
pCO2 Basic
HCO3 Acidic
O2 Slightly low, not by much

1. Has the status improved or not as expected to this point?

Yes patient has improved greatly

2. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?

a Yes

© 2016 Keith Rischer/www.KeithRN.com

3. Based on your current evaluation, what are your nursing priorities and plan of care?
a Specific antibiotics, Use of IS

It is has been two hours since Joan arrived in the ED. 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:
Name/age: 84 year old female who has possible pneumonia with COPD and possible sepsis

BRIEF summary of primary problem: Patient had difficulty breathing, fever, used albuterol inhaler with no
improvement. Patient called 911 and arrived at the emergency department

Day of admission/post-op #:

Background:
Primary problem/diagnosis: COPD, Asthma, hyperlipidemia

RELEVANT past medical history: COPD, Asthma, HTN, heart failure, anxiety, past smoker.

Assessment:
Vital signs: Temp: 100.8 F Pulse: 88 Resp: 24 BP: 128/90 O2 Saturations: 92% on 4 L nasal canula

RELEVANT body system nursing assessment data: Lungs are sounding better but coarse crackles are still there
in the lower left lobe

RELEVANT lab values: ABG: pH-7.31 pCO2- 55 HCO3-35

TREND of any abnormal clinical data (stable-increasing/decreasing): Patient is slowly stabilizing

INTERPRETATION of current clinical status (stable/unstable/worsening):

Recommendation:
Suggestions to advance plan of care: Suggestions to advance plan of care. Continue treatment plan, monitor
vitals, titrate O2 down if possible

Education Priorities/Discharge Planning

1. What will be the most important discharge/education priorities you will reinforce with her medical condition to
prevent future readmission with the same problem?

© 2016 Keith Rischer/www.KeithRN.com

 a Stay active, wash hands frequently, proper hygiene

2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?
a Verbalize understanding, use IO in front of staff

Caring and the “Art” of Nursing

1. What is the patient likely experiencing/feeling right now in this situation?
a Relief now that she can properly breath again

2. What can you do to engage yourself with this patient’s experience and show that she matters to you as a person?
a Pay attention to patient, smile, try to make them feel at ease.

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?
a How to identify COPD and Pneumonia signs and symptoms

© 2016 Keith Rischer/www.KeithRN.com

2. How can I use what has been learned from this scenario to improve patient care in the future?
a Notice signs and symptoms of this patient and relate it to similar patients in the field and treat them
accordingly.

© 2016 Keith Rischer/www.KeithRN.com