Pneumonia case study

 

Adapted from the Evolve case study guide page 273

 

CB is a 75 year old married female who presents to the outpatient clinic complaining of a severe cough, left sided chest pain that has become progressively worse over the past several days. She appears anxious and her face is flushed.  The physician suspects pneumonia.  Her vitals are as follows:

 

Temp:  102.6 F

BP:       120/80

HR:      118

RR:       32 shallow

 

 

1.       What is pneumonia and what are the major complications of this disorder? See Iggy page 659

 

2.       What causes pneumonia? (see etiology page 659)

 

3.       What are your concerns about the patient?  (Think biopsychosocial being)

 

4.        What is the cause of the concern?

 

5.        What information do you need?  Lets review the pneumonia algorithm

 

 

 

You learn that your client never seeks regular health examinations, has not received any vaccinations and hedged when asked about alcohol and cigarette smoking use. 

 

 

 

 

 

 

 

 

 

  1. What are you going to do about it?  Check the NCP in the chart (plan of care for Pneumonia) &  review the practice guidelines

 

  1. Based on what you understand about this disorder, what is the client experiencing?

 

The physician prescribed Ceclor and discharges the client home. 

 

  1. What concerns to have regarding the treatment regimen in view of the evidence?

 

 

  1. How should you communicate your concerns?

 

 

  1. What instructions should you provide to the client?

 

 

 

 

Following several days on Cefaclor (Ceclor) to which she did not respond, she required hospitalization for pneumonia and was started on IV Moxifloxacin in the emergency department.  Review standard MD orders.  What do you expect to be included in the plan of care?

 

·        IV

·        Medications

·        Oxygen therapy

·        Bloodwork

 

 

 

 

 

  1. What outcomes would you set for each potential complication?

 

a.         Hypoxia

b.         Ineffective breathing pattern

c.         Ineffective airway clearance

d.         Sepsis

e.         Hypovolemia

f.           Pain

g.         Activity intolerance

 

You are scheduled to care for CB on the medical surgical unit two days later.  You perform an initial assessment.

 

  1. Which of the following findings found on initial assessment would alarm you and which are expected?  (Select all that apply)

 

a.         Drowsy, but arousable and cooperative

b.         Chest soreness

c.         Productive cough

d.         6 degree F  decline in temperature

e.         Urine output 200 mL over 8 hours

f.           Wheezing

g.         Pulse oximetry 88%

 

 

 

You review the client’s laboratory reports:

 

Lab reports: Pneumonia client

Name

Barker, Cathy

 

 

Gender

F

 

 

 

 

 

DOB

1/1/1935

 

 

 

 

 

MR #

654321

 

 

 

 

 

Physician

Dr Thomas

 

 

 

 

 

Admitting date

1/9/2010

 

 

 

 

 

LABORATORY REPORT

DATE:

1/9/2010

1/10/2010

1/11/2010

Interpretation

TIME:

1200

600

0700

Lab Test

Reference Range

 

 

 

CBC and bleeding times

Complete Blood Count

 

 

 

 

HCT MALE

40-52%

 

 

 

HCT FEM

37-46%

37

38

35

HGB MALE

13.2-16.2 gm/dL

 

 

 

HGB FEM

12.0-15.2 gm/dL

12

11

10

RBC MALE

4.3-6.2x106/µL

 

 

 

RBC FEMALE

3.8-5.5x106/µL

3.7

3.9

 

WBC

4.1-10.9x103/µL

12.9

11.5

12

WBC Differential

 

 

 

 

PMN

35-80%

87

81

87

BANDS

0-10%

0

0

10

LYMPH

20-50%

45

45

 

MONO

2-12%

3

3

 

EOS

0-7%

2

2

 

BAS

0-2%

0

0

 

PLT

140-450x103/µL

201

200

100

BLEEDING TIMES

 

 

 

 

PT

12-14 seconds

12.6

12.8

15

PTT

18-28 seconds

26

26

32

METABOLIC PANEL

 

 

 

 

BMP

Sodium

137-145 mEq/L

145

137

146

Potassium

3.6-5.0 mEq/L

4.1

4.2

5.0

Chloride

99-108 mmol/L

99

99

99

Glucose

65-110 mg/dL

89

89

114

CO2

22-29 mmol/L

24

24

17

BUN

7-21 mg/dL

23

20

24

Creatinine

 

0.5-1.4 mg/dL

 

1.7

 

1.2

 

1.8

 

 

 

 

 

Top of Form

Bottom of Form

ARTERIAL BLOOD GAS

 

 RA

2lpm

 

ABG

pH

7.35-7.45

7.32

7.35

 

pCO2

35-45 mmHg

48

45

 

pO2

75-100 mmHg

69

75

 

HCO3

22-26 mEq/L

22

26

 

O2 SAT

95-100%

89

93

 

                   

 

Microbiology report

Specimen: Blood    Released   1/11/2010 0500

Organism: P aeruginosa

Antibiotics

susceptibility

 

AMK

S

 

GEN

S

 

Azactam

S

 

Moxifloxacin

MS

 

Zosyn

S

 

Timentin

S

 

 

 

 

How do you interpret these labs?

 

 

  1. Review the  standard MD orders.  What additional data should you collect?  Based on your findings what would be your next best action?

             Airway

             Breathing

             Circulation

             I/O

             wound

             pain

             safety

 

 

 

 

The rapid response team responds to stabilize the client.

 

 

  1. How do you think you responded to the client’s situation?

 

 

  1. What could you do differently?