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Solitiere Hunte
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 Judgment
5. Pain
6. Patient Education
7. Communication
8. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
,Solitiere Hunte
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:
Productive cough of phlegm for 4 days, chill This are starting to indicate the start of pneumonia; the fever and chills
and fever of 102, difficulty breathing, use of indicate an infection. Her difficulty breathing could mean she is not
inhaler q1-2 hours with no improvements. receiving enough oxygen. Her using the inhaler without any improvement
should be of great concern to the nurse, it means she is still not being
oxygenated enough.
RELEVANT Data from Social History: Clinical Significance:
Widowed, lives in assisted living, retired, and Her only support is no longer with her, assisted living can provide social
her feeling of hopelessness with her statement’ benefits but can still make the patient feel helpless. Her being retired
yes please, I feel that this may be the beginning means she is not as productive, so she probably is not getting exercise. She
of the end for me.’ sounds like she does not expect to live during the hospital stay.
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.Corticosteriod 1. Improve breathing.
• Hypertension diskus 1 puff every 12 hours 2.Bronchodilator 2. Open airway in lungs
• Hyperlipidemia 2. Albuterol MDI 2 puffs 3.ACE Inhibitor 3. Decrease blood pressure
• Cor-pulmonale every 4 hours prn 4.Cholesterol 4. Decrease fatty acids.
• Anxiety 3. Lisinopril 10 mg PO daily 5.Benzodiazepine 5. Decrease anxiety
• 1ppd smoker x40 years; 4. Gemfribrozil 600 mg PO 6.Potassium sparing diuretic 6. To help body decrease
quit 10 years ago bid sodium absorption and
5. Diazepam 2.5 mg PO prevent hypokalemia.
every 6 hours as needed
6. Triamterene-HCTZ 1 tab
PO daily
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)
, Solitiere Hunte
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:
Elevated temperature, Elevated temperature, pulse and blood pressure are more than likely related to infection and the
blood pressure and pulse, patient has a history of high blood pressure and heart failure so the BP should be watched.
breaths are deep and Respirations and low o2 indicates she is not being oxygenated enough systematically. Right
shallow, respirations were side chest pain indicates an infection more than likely occurring in the lung.
labored, low O2 despite
being on 6L, pain on right
side of chest.
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:
She has a barrel chest present with the use Patient may be experiencing a COPD exacerbation. Wheezing and diminished
of accessory muscles, dyspnea, wheezing, lungs sounds indicate fluid in her lungs. Her appearing anxious shows us that
and diminished lung sounds bilaterally. She she is having difficulty breathing.
is also anxious and in distress.
Solitiere Hunte
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 Judgment
5. Pain
6. Patient Education
7. Communication
8. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
,Solitiere Hunte
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:
Productive cough of phlegm for 4 days, chill This are starting to indicate the start of pneumonia; the fever and chills
and fever of 102, difficulty breathing, use of indicate an infection. Her difficulty breathing could mean she is not
inhaler q1-2 hours with no improvements. receiving enough oxygen. Her using the inhaler without any improvement
should be of great concern to the nurse, it means she is still not being
oxygenated enough.
RELEVANT Data from Social History: Clinical Significance:
Widowed, lives in assisted living, retired, and Her only support is no longer with her, assisted living can provide social
her feeling of hopelessness with her statement’ benefits but can still make the patient feel helpless. Her being retired
yes please, I feel that this may be the beginning means she is not as productive, so she probably is not getting exercise. She
of the end for me.’ sounds like she does not expect to live during the hospital stay.
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.Corticosteriod 1. Improve breathing.
• Hypertension diskus 1 puff every 12 hours 2.Bronchodilator 2. Open airway in lungs
• Hyperlipidemia 2. Albuterol MDI 2 puffs 3.ACE Inhibitor 3. Decrease blood pressure
• Cor-pulmonale every 4 hours prn 4.Cholesterol 4. Decrease fatty acids.
• Anxiety 3. Lisinopril 10 mg PO daily 5.Benzodiazepine 5. Decrease anxiety
• 1ppd smoker x40 years; 4. Gemfribrozil 600 mg PO 6.Potassium sparing diuretic 6. To help body decrease
quit 10 years ago bid sodium absorption and
5. Diazepam 2.5 mg PO prevent hypokalemia.
every 6 hours as needed
6. Triamterene-HCTZ 1 tab
PO daily
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)
, Solitiere Hunte
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:
Elevated temperature, Elevated temperature, pulse and blood pressure are more than likely related to infection and the
blood pressure and pulse, patient has a history of high blood pressure and heart failure so the BP should be watched.
breaths are deep and Respirations and low o2 indicates she is not being oxygenated enough systematically. Right
shallow, respirations were side chest pain indicates an infection more than likely occurring in the lung.
labored, low O2 despite
being on 6L, pain on right
side of chest.
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:
She has a barrel chest present with the use Patient may be experiencing a COPD exacerbation. Wheezing and diminished
of accessory muscles, dyspnea, wheezing, lungs sounds indicate fluid in her lungs. Her appearing anxious shows us that
and diminished lung sounds bilaterally. She she is having difficulty breathing.
is also anxious and in distress.
