Exam (elaborations)
Pneumonia-COPD Case Study - Joan Walker, 84 years old (answered)
Pneumonia-COPD Case Study - Joan Walker, 84 years old (answered)
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Pneumonia-COPD Case Study - Joan Walker, 84 years old(answered)
Pneumonia-COPD
JoanWalker,84yearsold
HistoryofPresentProblem:
Joan Walker is an 84-year-old female who has had a productive cough of green phlegm that started four days ago that
persists.Shewasstartedthreedaysagoonprednisone40mgPOdailyandazithromycin(Zithromax)250mgPOx5days 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/SocialHistory:
Joan was widowed six months ago after 64 years of marriage and resides in assisted living. She is a retired elementary
schoolteacher.ShecalledherpastorbeforecomingtotheEDandhehasnowarrivedandcamebackwiththepatient.The
nursewalkedintheroomwhenthepastoraskedJoanifshewouldliketopray.Thepatientsaidtoherpastor,“Yesplease, I feel that
this may the beginning of the end for me!”
©2016KeithRischer/www.KeithRN.com
This study source was downloaded by 100000865197380 from CourseHero.com on 11-15-2023 07:55:45 GMT -06:00
https://www.coursehero.com/file/101120594/FSA-Case-Study-Pneumonia-docx/
, Pneumonia-COPD Case Study - Joan Walker, 84 years old
(answered)
WhatdatafromthehistoriesareRELEVANTandhaveclinicalsignificancetothenurse?
RELEVANTDatafromPresentProblem: ClinicalSignificance:
Productivecoughwithgreenphlegm Thismaybethestartofpneumonia.Herhighfeverandchillsmay be a
X4days sign of infection. Her difficulty breathing could cause her to panic,
Chillandfeverovernightof102. Not getting enough air is a scary situation to be in. Using the
Difficultyofbreathingovernight inhalerwithnoimprovementshouldbeofconcerntothenurse
Use of inhaler
q1-2 hoursno improvement
RELEVANTDatafromSocialHistory: ClinicalSignificance:
Widowed Heronlysupportsystemisnolongerthere
Livesinassistedliving Retired Residinginassistedlivingishelpful(Shecaninteract,makenew friends,
Feelingofhopelessness and be interactive)
Retiredwhichmeansnotasproductiveassheoncewas
Shemaynotbegettingoutsideasmuchorexercisingasmuch She
thinks she will not survive this hospital stay
DevelopingNurseThinkingbyIdentifyingSignificanceofClinicalData Patient Care
Begins:
CurrentVS: P-Q-R-S-TPainAssessment(5thVS):
T:103.2F/39.6C(oral) Provoking/Palliative: Deepbreath/Shallowbreathing
P:110(regular) Quality: Ache
R:30(labored) Region/Radiation: Generalizedoverrightsideofchestwithnoradiation
BP:178/96 Severity: 3/10
O2sat: 86% 6litersn/c Timing: Intermittent–lastingafewseconds
WhatVSdataareRELEVANTandmustberecognizedasclinicallysignificantbythenurse?
RELEVANTVSData: ClinicalSignificance:
Hightemperature Thishightempcouldbeasignofinfection
Pulse is high Pulse is also high which again, could be due to infection, fever, or anxiety
There is labored RespirationsandrespirationsareveryhighandO2isverylow.(thisisamain concern
respiration because she is not getting enough oxygen into her system)
Blood pressure is high Canbecomehypoxicandessentially,sufferfromrespiratoryacidosis.
O2 is low even though
Bloodpressureisalsoelevated.Thisisaconcernbecauseshehasahistoryof elevated BP
sheison6Lofoxygen per
NC and heart failure.
Breathsaredeepand Sheiscomplainingofapainlevelof3/10andachinessovertheRsideofchest.
shallow
Painoverrightsideof
chest
©2016KeithRischer/www.KeithRN.com
This study source was downloaded by 100000865197380 from CourseHero.com on 11-15-2023 07:55:45 GMT -06:00
https://www.coursehero.com/file/101120594/FSA-Case-Study-Pneumonia-docx/
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