NUR347 NUR 347 Arizona State University STUDENT ETOH Withdrawal Pneumonia RAPID Reasoning

Arizona State University NUR 347 NUR 347 STUDENT-ETOH_Withdrawal-Pneumonia-RAPID_Reasoning ETOH Withdrawal/Pneumonia RAPID Reasoning Case Study Elena Acosta, 54 years old Primary Concept Addiction Interrelated Concepts (In order of emphasis) • Infection • Intracranial Regulation • Patient Education • Communication • Collaboration NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment • Management of Care 17-23% • Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% Psychosocial Integrity 6-12% Physiological Integrity • Basic Care and Comfort 6-12% • Pharmacological and Parenteral Therapies 12-18% • Reduction of Risk Potential 9-15% • Physiological Adaptation 11-17% Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. History of Present Problem: Elena Acosta is a 54-yr. old Hispanic woman with hypertension managed with hydrochlorothiazide. She is 63” (160.2 cm) and weighs 175 pounds (79.3 kg-BMI 31.0). She felt “crummy” and weaker the last 24 hours and called 911 when she began to have mid-sternal chest pain that increased with coughing and developed a harsh productive cough with green phlegm with difficulty breathing. Initial lab results: WBC 14.5, neutrophils 92%, Hgb 12.9, potassium 3.5, creatinine 1.1, total bili 0.9, ALT 42, chest xray revealed RLL infiltrate consistent with pneumonia, blood and sputum cultures collected and pending. Smell of ETOH present on her breath. Blood alcohol level 0.04, urine drug screen negative. She is admitted to the medical unit with a diagnosis of pneumonia. You are the nurse responsible for her care. Personal/Social History: Ms. Acosta works in a mid-level management position for a corporate finance company. She describes her job as quite stressful. She drinks 4-5 cups of coffee every day and to least 1-2 alcoholic drinks most days. She states that she shouldn’t smoke and has cut down to about ½ a pack per day. She reports drinking more and sleeping poorly following her father’s death over a year ago. She takes alprazolam as needed for sleep or when she feels more anxious. She is hesitant to be admitted because she has a high deductible insurance plan and doesn’t know how she will be able to afford it. What data from the histories are RELEVANT and have clinical significance to the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: -pt has been feeling crummy and weak the past 24 h and began to have mild chest pain that worsened with cough, cough produces green mucus and pt had difficulty breathing -neutrophils 92% -chest x ray -WBC 14.5 -blood alcohol 0.04, smell of ETOH on breath -diagnosed with pneumonia -pt is experiencing symptoms of possible respiratory infection -SOB related to impaired oxygenation and secretions in respiratory tract -increase in WBC indicates pt is experiencing infection -increase of neutrophils indicates possible bacterial infection, because it is such a high level it needs immediate attention -xray revealed infiltrate consistent with pneumonia -ETOH smell and blood alcohol level indicates patients was possibly drinking before admission RELEVANT Data from Social History: Clinical Significance: - Mid level management, describes stressful job - Drinks 4-5 cups of coffee every day and 1-2 alcoholic drinks most days - Cut down on smoking - Stressful jobs and being female put the client at increased risk for anxiety, depression and suicide - Caffeine can mask the effects of alcohol and can cause the patient to drink more which can be a safety issue - The patient has made progress cutting down with her- Father died over a year ago, has been drinking more and sleeping less since - Scared of being admitted due to high insurance deductible smoking but stressors can cause her to relapse - Losing an important person in your family also contributes to stress, assess maladaptive coping and coping mechanisms - Patient is hesitant to receive care due to financial strain it can place Patient Care Begins: Initial Assessment Medical Unit Current VS: P-Q-R-S-T Pain Assessment: T: 101.2 F/38.4 C (oral) Provoking/Palliative: nothing P: 96 (regular) Quality: ache R: 28 (regular) Region/Radiation: Denies chest pain currently/Headache-global BP: 138/88 Severity: 5/10 O2 sat: 92% room air Timing: constant What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: -Temp: 101.2 F -P: 96 -O2 : 92%, RR 28 -headache 5/10 -BP: 138/88 -indication of a fever due to infection, result of the inflammatory response -pulse within the normal limits but it a bit high, most likely due to anxiety or fever from infection, continue to monitor -low oxygenation and increased respirations due to respiratory infection, causing an impairment of breathing, respirations could also be increased due to anxiety and pain or possible alcohol consumption -pt is experiencing pain, could be possible indication of alcohol withdrawal -monitor, pt has history of hypertension Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. Current Assessment: GENERAL SURVEY: Looks older than stated age, alert, oriented, pleasant, in no acute distress, calm, body relaxed, no grimacing, appears to be resting comfortably. NEUROLOGICAL: Alert & oriented to person, place, and situation (x3), knew year, but wrong day of week, feels fatigued with chills, weak, no focal deficits HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. RESPIRATORY: Breath sounds bibasilar crackles posteriorly, diminished aeration RL bases, unlabored respiratory effort on room air, productive cough with moderate amount thick yellow/brown tinged sputumCARDIAC: Pink, warm & dry, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-E-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Abdomen round, soft, and nontender. BS + in all 4 quadrants GU: Voiding without difficulty, urine clear/yellow INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill 3 seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present. What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: - Neurological: alert and oriented x3, chills and weak - Resp: crackles, diminished aeration, productive cough with yellow sputum - Patient is not oriented to day of the week, assess further to determine potential causes - Yellow sputum can be indicative of infection and should be assessed further. Possible cause for diminished aeration should be determined Clinical Reasoning Begins… 1. Interpreting relevant clinical data, what is the primary problem? What primary health related concepts does this primary problem represent? (Management of Care/Physiologic Adaptation) Problem: Pathophysiology of Problem in OWN Words: Primary Concept: - Community acquired pneumonia - This is the kind of pneumonia that people get outside of the hospital and can be caused by several pathogens or even a virus. It causes inflammation of the air sacs in one or both lungs - Patient is at risk for impaired gas exchange Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. 2. Collaborative Care: Medical Management (Pharmacologic and Parenteral Therapies) Care Provider Orders: Rationale: Expected Outcome:Supplemental O2 per nasal cannula at 2 L/min. for O2 sat 93 % VS every 4 hours and as needed Levofloxacin 500 mg IV in Sodium chloride 0.9% solution to infuse over 60 minutes Hydrochlorothiazide 50 mg PO daily Acetaminophen 325-650 mg PO every 4 hr PRN pain/temp 101; not to exceed 4000 mg/day -pneumonia puts pt at risk for imapired gas exchange, supplemental O2 needed for adequate oxygenation -VS need to be assess to monitor for any changes from baseline that could indicate possible sepsis -antibiotic used to prevent bacterial growth by inhibiting DNA gyrase needed for replication -antihypertensive medication used to bring down pt blood pressure -used to control pt fever and any possible pain -pt will have O2 stats 92% -Pt’s VS will remain WNL, no indications of sepsis -Pt will have a decrease in WBC and neutrophils, Pt’s bacterial infection will be eliminated -Pt’s BP will be within normal limits -Pt’s fever will subside, Pt will not experience pain Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: -imapired gas exchange PRIORITY Nursing Interventions: Rationale: Expected Outcome: - Provide education on methods for airway clearance (cough, deep breath, spirometer) - Assess respiratory system to monitor for changes, oxygen as needed - Regulate body temperature - Promote sleep/ rest - Assess the patients pain and give medications as needed - Based on the ABC’s we must first address issues with airway - By assessing and monitoring the resp. System we can determine interventions such as oxygen therapy - Maintaining body temp. within normal range will maximize oxygenation - Patient is at risk for injury due to inadequate sleep - Patients pain must be kept at a low level - patients airway is cleared -oxygen therapy as needed -body temp kept within normal range -patient will get adequate rest -patient pain will be managed 4. What body system(s) will you assess most thoroughly based on the primary/priority concern? (Reduction of Risk Potential/Physiologic Adaptation) PRIORITY Body System: PRIORITY Nursing Assessments: -respiratory -To assess this patient, we need to monitor her pulse oxygenation, RR and depth, indications of SOB such as pursed lips, cyanosis or nasal flaring,quality and pattern of respirations -we need to ensure her lung sounds are normal by auscultating each lobe and check for crackles, crepitus, tenderness, fremitus or any other abnormal breath sounds -ensure her positioning is appropriate (Fowlers or Semi-Fowlers) Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. 5. What is the worst possible/most likely complication(s) to anticipate based on the primary problem of this patient? (Reduction of Risk Potential/Physiologic Adaptation) Worst Possible/Most Likely Complication to Anticipate: -Sepsis or ETOH withdrawal Nursing Interventions to PREVENT this Complication: Assessments to Identify Problem EARLY: Nursing Interventions to Rescue: -frequently monitor the patient's vital signs for indications of sepsis and use the CIWA scale if any symptoms of withdrawal are present -increased HR, increased RR, increased BP -tachycardia, agitation, confusion, tremors, sweating, headache -contact provider, administer IV fluids and medications, treat bacterial sepsis -contact provider, begin ETOH protocol, use benzos Unfolding: Day #2 at 0100… The nurse finds Ms. Acosta fully awake. Reports she was starting to feel better because she was able to rest and eat a little food. Now she feels worse again, but in a “different way”. The nurse completes a focused respiratory assessment and general health assessment. Review the following reported signs and symptoms. Current VS: 4 Hours Ago: Current PQRST: T: 99.0 F/37.2 C T: 98.6 F/37.0 C Provoking/Palliative: Bright lights make pain worse P: 110 (reg) P: 98 (reg) Quality: Throbbing like an elastic band around my head R: 20 (reg) R: 20 (reg) Region/Radiation: headache BP: 154/92 BP: 136/84 Severity: 7/10 O2 sat: 95% RA O2 sat: 94% RA Timing: Constant What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance:- P: 110 -RR: 20 -BP:154/92 -Headache 7/10 - Pulse/ heart rate has increased since admission, may be tachycardic - RR are on the higher end of the scope, should be monitored - BP increased, may be related to alcohol withdrawal but needs to be assessed - Headache and light sensitivity are hallmarks for ETOH withdrawal, should be assessed Current Assessment: GENERAL SURVEY: Dressed in hospital gown; appears uncomfortable; restless; constantly repositioning self in bed NEUROLOGICAL: Alert & oriented to person, and place, did not know where she was or the day of the week; moderate hand tremors when asked to extend both arms HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort; O2 sat: 95% on room air or oxygen? Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. CARDIAC: Pink, warm & dry, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-E-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Abdomen round, soft, and nontender. BS + in all 4 quadrants, no appetite, upset stomach with nausea; no vomiting GU: Voiding without difficulty, urine clear/yellow INTEGUMENTARY: Forehead moist, skin warm, and intact, normal color for ethnicity. No clubbing of nails, cap refill 3 seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present Mental Status Examination (MSE): APPEARANCE: Moderately overweight woman; Looks fatigued and anxious. Less willing to answer assessment questions currently “Just leave me alone, please”. Disheveled appearance. Reports currently having difficulty sleeping MOTOR BEHAVIOR: Moderate hand tremor when asked to extend arm twitching, reports feeling shaky inside, frequent repositioning noticed SPEECH: Normal rate and rhythm; occasionally slow to respond MOOD/AFFECT: c/o fatigue and mild depression; intense anxiety; 7 out of a possible 10; irritable andtearful at times THOUGHT PROCESS: Linear and logical THOUGHT CONTENT: Preoccupied with physical symptoms; no evidence of delusions PERCEPTION: Denies hallucinations; reports being bothered by bright lights and noise of the unit INSIGHT/JUDGMENT: Difficult to assess at this time; continues to recognize need for hospitalization for symptoms of pneumonia; seems to understand drinking as a coping strategy for increased stress and not a problem by itself COGNITION: Generally oriented but date is off by 2 days SUICIDAL/HOMICIDAL: Denies suicide, homicide or self-harm ideation What clinical data are RELEVANT that must be recognized as clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT Assessment Data: Clinical Significance: -pt appears uncomfortable, restless and is constantly repositioning herself -pt did not know what day it was or where she was, pt had moderate hand tremors when asked to extend arms -moist forehead -this can be an early indication of withdrawal -symptoms aligned with alcohol withdrawal syndrome, pt at risk for seizures depending on severity of symptoms -sweating is an symptom of someone who is withdrawing RELEVANT MSE Assessment Data: Clinical Significance: - Patient is twitching, feeling shaky, hand tremors, anxiety and irritability - Does not identify drinking as a problem - These symptoms are hallmark for mild/ moderate ETOH withdrawal - Patient may be at risk for noncompliance since she is in denial of a possible drinking problem Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? (Management of Care, Physiological Adaptation) Evaluation of Current Status: Modifications to Current Plan of Care:There was a complication in status due to the patient experiencing symptoms of acute withdrawal syndrome. - At this moment AWS should be addressed, the nurse should use the CIWA scale to determine how to proceed and see if the physician needs to be contacted for prescriptions.