Pneumonia/Chronic Obstructive Pulmonary Disease Clinical Reasoning Case Study

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 with the inhaler, productive cough of green phlegm. This is important because we need to look at the relevant data and realize that she seems to be in distress and first take care of that. 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 married for 64 years, and she feels like it is the beginning of the end for her. This is important because when caring for her we need to keep in mind her age, stressors in her life and any limitations