Elena Acosta 54 year old NURS 1251 ETOH Withdrawal Pneumonia Rapid Reasoning Case Study
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NURS 1251
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NURS 1251
Elena Acosta 54 year old NURS 1251 ETOH Withdrawal Pneumonia Rapid Reasoning Case Study/Elena Acosta 54 year old NURS 1251 ETOH Withdrawal Pneumonia Rapid Reasoning Case Study/Elena Acosta 54 year old NURS 1251 ETOH Withdrawal Pneumonia Rapid Reasoning Case Study/Elena Acosta 54 year old NURS 1251 ...
elena acosta 54 year old nurs 1251 etoh withdrawal pneumonia rapid reasoning case studyelena acosta 54 year old nurs 1251 etoh withdrawal pneumonia rapid reasoning case studyelena acosta 54 year old
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ETOH Withdrawal/Pneumonia
RAPID Reasoning Case Study
, 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
x-ray 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:
-- gives us information on patient's pre-existing condition and
-hypertension managed with medication being taken
hydrochlorothiazide
-- this means patient is obese and is at risk for other health
-BMI 31.0 diseases
- this means patient condition is of acute onset
-"crummy" and weaker the last 24 hours
- symptoms help us come up with appropriate diagnosis, it could
-midsternal chest pain that increased with be respiratory or cardiac issues
coughing, harsh productive cough with
green phlegm with difficulty breathing
- WBC 14.5; neutrophil 92% - these values are elevated which mean patient has an infection
-
-chest x-ray: infiltrates on RLL - supports the diagnosis of pneumonia
- means patient had an intake of alcohol which can possibly have
effects on medications being taken.
-Blood alcohol level 0.04
, RELEVANT Data from Social History: Clinical Significance:
- these increases her risk of having health problems, and
stressful job; 4-5 cups of coffee could worsen her hypertension
every day; 1-2 alcoholic drinks
most days; smokes 1⁄2 a pack
per day; drinking more and
sleeping poorly
takes alprazolam - when mixed this could lead to life-threatening conditions
with alcohol
-At risk for depression
loss of a love one
- this could hinder patient's cooperation and compliance
with medical services.
hesitant to be admitted
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:
T: 101.2 F/38.4 C (oral) -- means patient is febrile, consistent with Pneumonia, typical response to a
bacterial infection to increase the production of neutrophils w/c are the first
R: 28 (regular responders of the inflammatory response
BP: 138/88
- increased, could support the impression that patient needs more oxygen,
O2 sat: 92% elevated d/t anxiety and respiratory distress/headache
-high, consistent with hypertension
-decreased which means her breathing is inefficient to meet oxygen demand
Pain
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