RELEVANT Data from
productive cough with green phlegm
2. Prednisone 40mg and
Azithromycin 250 mg three days ago
3. Chills and Fever
4. Difficulty breathing at night
and using albuterol inhaler w/o improvement
1. This is a sign of infection
and the body trying to fight it off.
2. Prednisone is used for
inflammation and azithromycin is used to fight against susceptible bacteria.
3. Chills and fever are also
signs of infection.
4. Difficulty breathing w/o
improvement from inhaler means that O2 is decreasing in the lungs and she is
All of these point me toward a
RELEVANT Data from
1. Widowed 6 months ago
2. Assisted living
3. Called pastor
4. Beginning of end
1. She is still going
through loss of husband and many emotions come from that.
2. Assisted living and being 84
means she is more susceptible to infections
3. Religious person and may need
pastor to help with coping
4. Thinking that this may be the
beginning of the end shows a poor outlook on her life and may need to be
addressed later after primary problem is under control.
RELEVANT VS Data:
Temperature of 103.2
degrees F, Pulse rate of 110, Respiratory rate of 30, blood pressure of
178/96, 86% oxygen saturation are vitals so be concerned with. First the
oxygen saturation of 86% means that not enough oxygen is getting to the lungs
and part of the respiratory system is compromised. This could be due to her
COPD or if she has asthma. High temperature is still showing that there is an
infection that the body is trying to fight off. Blood pressure of 178/96
shows signs of hypertension or due to pain. Pulse of 110 could be because of
the pain she is experiencing and is regular, so it is classified as sinus
tachycardia. (Lewis et al., 2017, p. 763) Her pain is achy on deep breathing
and shallow breathing, and generalized over the right side and intermittent is
probably caused by inflammation and coughing for four days or COPD
Anxious and distress
Dyspnea with accessory muscles
Diminished breath sounds
Pale, hot & dry
Alert and Oriented x4
Patients who are anxious and in
distress can increase blood pressure and pulse. Barrel chest is a sign of
COPD. Dyspnea with accessory muscles tells us that she is having a hard time
breathing and is seen in COPD (ATI, 2016, p. 129). Diminished breath sounds,
and expiratory wheezing could be a sign of asthma exacerbation (Lewis et al.,
2017, p. 466). Hot to the touch tells us her temperature is elevated which
was stated before showing signs of infection. Patient is alert and orientated
x4 which is showing that she has not had neuro complications yet with present
problem. Decreased oxygen can cause altered mental status.
12 Lead EKG
“Sinus tachycardia is associated
with physiologic and psychologic stressors such as exercise, fever, pain,
hypotension, hypovolemia, anemia, hypoxia, hypoglycemia, myocardial ischemia,
heart failure (HF), hyperthyroidism, anxiety, and fear” (Lewis et al., 2017,
p. 763). HR for ST is above 100 bpm with normal p wave, along with QRST.
Left lower lobe infiltrate.
Hypoventilation present in both lung fields
Fluid build up in lower left lobe
which is a sign of pneumonia and hypoventilation happens in exacerbation of
COPD (ATI, 2016, p. 112).
Complete Blood Count (CBC)
WBC (4.5–11.0 mm 3)
Hgb (12–16 g/dL)
Neutrophil % (42–72)
Band forms (3–5%)
Neutrophils take in the bacteria
first as they are the first to respond to an injury. They have a short life
so more must be produced rapidly and with that WBC increase also. Band forms
are immature neutrophils and are found more in acute bacterial infections. (Lewis et al., 2017, p. 160)
WBC – Increasing
Neutrophils – Increasing
Band forms – Improving
Basic Metabolic Panel (BMP:)
Sodium (135–145 mEq/L)
Potassium (3.5–5.0 mEq/L)
CO2 (Bicarb) (21–31 mmol/L)
Glucose (70–110 mg/dL)
BUN (7–25 mg/dl)
Creatinine (0.6–1.2 mg/dL)
Lactate (0.5–2.2 mmol/L)
Sodium, potassium, CO2, Glucose,
BUN, and lactate.
Sodium and potassium being within
normal limits meaning the body is trying to stay in homeostasis. Sodium
determines extracellular fluid osmolality and potassium determines
intracellular fluid osmolality. (Lewis et al., 2017, p. 278-280) CO2,
Glucose, BUN and lactate being high means acidosis. CO2 is bicarbonate and is
affected by lung function. Glucose is high possibly from taking prednisone.
(Prednisone, n.d.) BUN is normally higher in older adults due to changes in
the body. (Lewis et al., 2017) It can also be elevated due to the
azithromycin she was prescribed. (Azithromycin, n.d.) Lactate “usually
increases once significant hypoperfusion and impaired O2 utilization at the
cellular level have occurred. By-product of anaerobic metabolism” (Lewis et
al., 2017, p. 1589).
Lactate: Increased (not prior
Arterial Blood Gas:
O2 sat (>92%)
pH, pCO2, pO2, HCO3, O2
Low pH means the blood is acidic
and could be caused by Ventilatory failure, pulmonary diseases, pulmonary
edema, renal failure, lactic acidosis and ketoacidosis. pCO2 being high means
too much CO2 is in the body and that is caused by pulmonary edema and obstructive
lung disease. pO2 being low tells us that there is not enough oxygen in the
blood and can be caused by COPD, restrictive pulmonary disease and
hypoventilation. HCO3 is bicarbonate and is mostly controlled from the
kidneys. HCO3 neutralizes acid in the blood. O2 saturation being low also
meaning not enough oxygen is getting into the body this could be due to an
airway obstruction such as during an asthma attack or lung diseases like
COPD. (“ABG (arterial blood gases)”, n.d.) These are all characteristics of
respiratory acidosis. (Lewis et al., 2017, p. 288)
Urine Analysis (UA):
Specific Gravity (1.015–1.030)
LET (Leukocyte Esterase) (neg)
RBCs ( normal mL
needed/day unless contraindicated.
– Give nebulizer and other
medications as prescribed by doctor
– Monitor labs and other tests for
improvement or decline including x-rays, ABG’s and BMP.
2. Impaired gas exchange
– Assess mental status.
– Monitor heart rate and rhythm.
– Monitor body temperature.
– Elevate head and encourage
frequent position changes, deep breathing, and effective coughing.
– Assess anxiety level
– Observe for deterioration
– Administer oxygen therapy
3. Risk of infection
– Monitor vital signs closely
– Teach patient about secretions
and how they look. They need to report any changes.
– Limit visitors if indicated to
make sure infection doesn’t spread.
– Rest and activity need to be
– Tell patient to report deterioration
4. Acute Pain
pain and characteristics. Report changes in feeling
– Provide comfort: position
changes, and medications.
– Oral hygiene needs to be
– Assessment of the respiratory
system can help determine a basis of what is going on.
– Auscultation of lungs can be
clear which is normal. Crackles, rhonchi, and wheezes and can be heard as
abnormalities and can be due to fluid, thick secretions, spasms and
– Deep breathing, splinting, and
effective coughing provide expansion, patent airways, and reducing discomfort.
– “Nebulizers and other
respiratory therapy facilitates liquefaction and expectoration of secretions.
Postural drainage may not be as effective in interstitial pneumonias or those
causing alveolar exudate or destruction. Coordination of treatments and oral
intake reduces likelihood of vomiting with coughing, expectorations” (Vera,
2013, p. 1).
– Laboratory results and other
tests being monitored can help with seeing if the patient is progressive
further into diseases or improving to normal state.
– Any change in mental status
could be caused by impaired gas exchange from the lungs or any point in the respiratory
– Fever can cause tachycardia of
“High fever greatly increases
metabolic demands and oxygen consumption and alters cellular oxygenation”
(Vera, 2013, p. 2).
– Anxiety can happen when a person
is going through something and doesn’t know how to handle it. Helping with
relaxation and medications will calm patient.
– Shock and pulmonary edema are
the most common causes of death in pneumonia
– Continuous oxygen therapy needs
to be given to her because of COPD and patient needs to be able to exchange
as much oxygen as possible when airway is cleared.
– Deathly complications can
develop as a side effect of therapy. It is not likely.
– If characteristics change
patient needs to report as it can mean improvement or decline into another
– Patient can spread infection so
visitors need to be limited to reduce the risk.
– Ineffective activity is a
diagnosis with someone who has a rough time breathing. Too much activity can
cause problems further than what they are experiencing.
– Symptoms of shock and or any
other complication can develop or deterioration. Any change of symptoms need
to be reported.
– Characteristics of pain can help
narrow down what is being felt and why. They can also tell us complications
of what is already being felt and reported.
– Comfort measures whether
nonpharmacological or pharmacological can help. Try non-pharmacological first
then result to medications.
– From pneumonia and COPD
exacerbations mouth breathing and oxygenation therapy makes dry mouth and
membranes. Oral hygiene will help with discomfort.
– Identify and help with behaviors
to clear airway
-Get patent airway and continue to
have one without complications.
-Improve ventilation and
– Teach and participate in actions
to increase oxygenation
– Resolution of infection
– Prevent spread of infection
– Control pain
– Decreased anxiety and more
What body system(s) will you most thoroughly assess based on
the primary/priority concern?
What is the worst possible/most likely complication to
“Sepsis/septic shock can occur when
bacteria within alveoli enter the bloodstream. Severe sepsis can lead to shock
and multisystem organ dysfunction syndrome” (Lewis et al., 2017, p. 502).
What nursing assessments will identify this complication
EARLY if it develops?
rapid heart rate, rapid breathing, low BP, altered mental status, edema, high
glucose without diabetes. (Lewis et al., 2017, p. 1591)
What nursing interventions will you initiate if this
assess ABC’s first. If patient goes unresponsive and there is no signs of life,
CPR must be started. If responsive still monitor ABC’s, give high flow oxygen,
prepare for intubation, make sure previous IV access is patent clean dry and
intact. Labs need to be drawn; CBC, BMP, ABG’s to assess patient’s status. Start
medications as ordered by physician including antibiotics to take care of
bacteria. Continuously monitor vitals, labs, and urine output. (Lewis et al.,
What psychosocial needs will this patient and/or family
likely have that will need to be addressed?
Fear, anxiety, agitation, depressed,
How can the nurse address these psychosocial needs?
patient needs to know that all emotions are acceptable when in a situation like
this. Explaining the situation and how things will go to the family may calm
the family and patient. Keeping a calm environment and making communication
important may help ease some emotions. The family needs to know that they have
to communicate their thoughts and feelings. Without communication feelings will
be bottled up and things can get out of hand. Family needs to be included in
all aspects of care the patient is not alone in this.
What is the patient likely experiencing/feeling right now in
patient is an older woman who has had COPD for a while now. She probably knows
the extent of her illness but pneumonia and possibly acidosis may be new to
her. She is probably fearful and anxious. As the nurse we need to make sure she
has all the information she can get and everything is explained fully.
What can you do to engage yourself with this patient’s
experience and show that she matters to you as a person?
patient information, comfort, encourage communication, perform skills
competently, ask questions, and educate.
What did I learn from this scenario?
learned a lot from this scenario including labs and more signs and symptoms
with COPD, pneumonia, and acidosis. Airway breathing and circulation no matter
what the condition or system those are always most important. I also didn’t
know about lactate and how it connects with other labs and what it could
possibly point towards.
How can I use what has been learned from this scenario to
improve patient care in the future?
scenario really made me realize how important labs are in any condition that
could be happening. No matter how small the task or order they are all
important. Critical thinking and analysis are important in nursing care.
Knowing that the patient came in with COPD exacerbation and easing the breathing
is more important then IV access for medications. I’m glad that the DuoNeb was
made as it really helps in situations like this. Didn’t think that COPD would
really turn into acidosis and could have a possible complication of
sepsis/septic shock. Things can go down hill fast.
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