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:
JoAnn Walker is an 84-year-old female who has had a productive cough of green phlegm...
1 1 [Date] Airway/Breathing (Oxygenation) Pneumonia/Chronic Obstructive Pulmonary Disease Clinical Reasoning Case Study 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 di scussion 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 s s 2 2 [Date] Pneumonia -COPD I. Data Collection History of Present Problem: 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 improvementThis 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: CO P D/ a st h ma 1. Fluticasone/salmeterol 1. corticosteroid 1. improve breathing • Hypertension (Advair) diskus 1 puff every 2. bronchodilator 2. open up airway in the lungs • Hyperli pidemia 12 hours 3. ACE inhibitor 3. decrease blood pressure and • Cor-pul monale 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
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