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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 Judgement
5. Pain
, 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 continues to persist. 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 last night and has been using her albuterol inhale every 1-2 hours
with no improvement so she called 9-1-1 and is 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 be 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:
Productive cough The patient is presenting with an infection of
Green phlegm the respiratory system, this needs to be
Condition is Persistent addressed and treated quickly as it could
Albuterol is not working effectively result in respiratory failure.
High fever
RELEVANT Date from Social History Clinical Significance
Lost her husband 6 months ago The patient may feel depressed and lonely
She finds comfort in her pastor and since losing her husband. She may also lose
prayer her will to survive if she fears or believes this
She fears this is the end for her is the end for her, this could cause additional
Resides in assisted living home issues and stress.
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
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 Judgement
5. Pain
, 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 continues to persist. 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 last night and has been using her albuterol inhale every 1-2 hours
with no improvement so she called 9-1-1 and is 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 be 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:
Productive cough The patient is presenting with an infection of
Green phlegm the respiratory system, this needs to be
Condition is Persistent addressed and treated quickly as it could
Albuterol is not working effectively result in respiratory failure.
High fever
RELEVANT Date from Social History Clinical Significance
Lost her husband 6 months ago The patient may feel depressed and lonely
She finds comfort in her pastor and since losing her husband. She may also lose
prayer her will to survive if she fears or believes this
She fears this is the end for her is the end for her, this could cause additional
Resides in assisted living home issues and stress.
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
