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Unfolding Case Study Pneumonia-COPD
Case Study (with answers)
Pneumonia-COPD
1. Data Collection History of Present Problem: Joanne Walker is an 84-year-old female who has had a productive cough of green phlegm 4 days that continues to persist. She was started 3 days ago on prednisone 60 mg PO daily and azithromycin (Zithromax) 250 mg PO X 5 days by her clinic physician. Though she has had intermittent chills, she first noticed a fever last night of 102.0º F. She has had more difficulty breathing during the night and has been using her albuterol inhaler every 1-2 hours with no improvement. Therefore, she called 9-1-1 and arrives at the emergency department (ED) by emergency medical services (EMS) where you are the nurse who will be responsible for her care. Joanne has a history of COPD and has a history of smoking 1 PPD x 40 years. She quit 10 years ago. She also has a history of hypertension, hyperlipidemia, and Cor Pulmonale secondary to her COPD which is being treated with medications. Personal/Social History: Joanne was widowed 6 months ago after 64 years of marriage and resides in assisted living. She is a retired elementary school teacher. She called her pastor and he has now arrived and came back with the patient. The nurse walked in the room when the pastor asked Joanne if she would like to pray. The patient said, “Yes, this may be the beginning of the end for me.” What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: Productive cough of green phlegm 4 days ago that continues to persist. Started 3 days ago on prednisone 60 mg PO daily and azithromycin (Zithromax) 250 mg PO X 5 days by her clinic physician. A productive cough with color is always a red flag. Sputum that is various shades of yellow to green is typical of dead neutrophils that are present because the neutrophils have responded to a bacterial infection. Knowing that this respiratory infection was treated by an antibiotic and steroids, the nurse must be able to use the nursing process and determine if this medical treatment has been effective or not. Based on the progression of respiratory distress it
clearly has not, and may be either due to an asthmatic exacerbation or an infection that is not susceptible to azithromycin. Prednisone is used in patients when the bronchioles constrict or narrow due to Fever last night of 102.0º F. More difficulty breathing during the night and has been using her albuterol inhaler every 1-2 hours with no improvement. swelling associated with inflammation. This swelling can impair ventilation. Prednisone impacts the body’s ability to fight infection because it can blunt the immune response and therefore, can further increase the risk of infection. The relationship between sputum with color and elevated temperature must be recognized. This is a typical response to a bacterial infection as the body raises the temperature to increase the production of neutrophils which are the first responders of the inflammatory response! This clinical data clearly has a relationship with the fever and productive sputum that must be recognized by the nurse. A respiratory infection is clearly suggested and with known history of COPD, pneumonia that is causing difficulty in breathing is another red flag in this presentation. RELEVANT Data from Social History: Clinical Significance:
PMH: Home Meds Pharm. Classification Expected Outcome:
- COPD/asthma
- Hypertension
- Hyperlipidemia
- Anxiety disorder
- 1 ppd smoker X 40 years. Quit 10 years ago.
- Cor-pulmonale
- Fluticasone/salmetro l (Advair) diskus 1 puff every 12 hours
- Albuterol (Ventolin) MDI 2 puffs every 4 hours prn
- Lisinopril (Prinvivil) 10 mg po daily
- Gemfribrozil (Lopid) 600 mg po bid
- Diazepam (Valium) 2.5 mg po every 6 hours as needed
- Triamterene-HCTZ (Dyazide) 1 tab daily
- Anti-inflammatory
- Bronchodilator
- ACE inhibitor
- Antihyperlipidemi c
- Benzodiazepine
- Diuretic
- Control of asthma
- Improved ventilation
- Decreased BP
- Decreased cholesterol
- Decreased anxiety
- Increased u/o; decreased BP (Which medications treats which condition? Draw lines to connect)
- Fluticasone/salmeterol (Advair) diskus 1 puff every 12 hours>>>COPD/asthma
- Albuterol (Ventolin) MDI 2 puffs every 4 hours prn>>>COPD/asthma
- Lisinopril (Prinivil) 10 mg po daily>>>hypertension
- Gemfribrozil (Lopid) 600 mg po bid>>>hyperlipidemia
- Diazepam (Valium) 2.5 mg po every 6 hours as needed>>>anxiety
- Triamterene-HCTZ (Dyazide) 1 tab daily>>>hypertension One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that then initiated a “domino effect” in their life?
- Circle what PMH problem likely started FIRST o 1 PPD smoker x 40 years; quit 10 years ago
▪ This is what started the domino to fall and is responsible for
the respiratory complications in her history.
- Underline what PMH problem(s) FOLLOWED as domino(s) o COPD/asthma o Cor-pulmonale
▪ Otherwise known as right ventricular heart failure. Is a result of the
increased resistance (pulmonary hypertension secondary to chronic hypoxemia) the right ventricle must overcome to pump blood to the lungs. o Hypertension
▪ Though cardiovascular in origin, smoking is also known to contribute
to this problem. Nicotine is a very potent vasoconstrictor. o Hyperlipidemia
D uration: Intermittent-lasting a few seconds By situating your knowledge of what is expected with cardiac chest pain, pain that lasts only a few seconds at a time does not fit a cardiac etiology. Anginal pain lasts minutes. Not seconds. A ggravate: Deep breath A lleviate: Shallow breathing This clinical data clearly supports a respiratory origin or pleuritic chest pain. Cardiac chest pain is not influenced by deep breaths or relieved with shallow breathing. If a rapid response team (RRT) was activated, this clinical data promptly communicated to the RRT nurse will help guide clinical decision making. A 12 lead EKG is standard with any complaint of chest pain and will be relevant to conclusively rule out a cardiac origin of this pain. Current Assessment: GENERAL APPEARANCE: Appears anxious and in distress. RESP: Dyspnea with intercostal retractions, breath sounds very diminished bilaterally with scattered expiratory wheezing CARDIAC: Pale, hot & dry, no edema, heart sounds regular-S1, S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact What assessment data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Assessment Data: Clinical Significance: GENERAL APPEARANCE: Appears anxious and in distress Clustered with the VS data, this is relevant because of the hypoxemia that is clearly present. This distress is confirming the validity of the seriousness of this presentation. RESP: Dyspnea with intercostal retractions, breath sounds very diminished bilaterally with scattered expiratory wheezing Retractions must be recognized as a clinical red flag! Why are they present? In respiratory distress, the skeletal muscles can be used to help improve ventilation. Diminished aeration could be her baseline due to COPD, but must be recognized. Wheezing represents narrowed bronchioles that are whistling, Expiratory wheezing is more common and typically indicates less severe bronchoconstriction. Inspiratory wheezing with expiratory wheezing can represent more severe narrowing and must be recognized as a clinical red flag by the nurse. CARDIAC: Pale, hot & dry This^ data^ is^ confirming^ the^ presence^ of^ a^ fever^ that^ is^ already known.
GU: Voiding without difficulty, urine clear/yellow Though these are normal findings, this is an excellent example of the importance of the nurse’s recognizing relevant normal findings. Knowing that this is an elderly female with a likely infection, the presence of a urinary tract infection (UTI) must also be considered. Knowing that there is no painful, burning or frequency of urination, this is likely not a contributing problem. III. Clinical Reasoning Begins…
1. What is the primary problem that your patient is most likely presenting with? Acute respiratory distress that represents the commonly seen relations of COPD exacerbation caused by pneumonia. 2. What is the underlying cause/pathophysiology of this problem? First some quick facts on pneumonia: - Is an acute inflammation of lung tissue caused by bacterial or viral organisms. o Community acquired—patient is admitted with or develops within 48 hours of hospitalization. o Hospital acquired—patient develops after 48 hours of admission to the hospital. o Ventilator-associated—patient develops after being intubated and placed on ventilator. o Opportunistic—immunocompromised patients (HIV and/or chemotherapy patients). - Seventh leading cause of death…#1 cause of death from infectious disease in the US. - Lower airway is sterile--therefore organisms reaching this far is because of aspiration than inhalation. - Streptococcus pneumonia is the most common community acquired organism — causes 40,000 deaths and 500,000 illnesses in the US annually. - Because of their damaged and diseased lungs any patient with COPD is a susceptible host. The 4 stages of pneumonia progression typically include the following:
- Congestion: After the pneumococcus organisms reach the alveoli, there is an outpouring of fluid into the alveoli. The organisms multiply in the serous fluid, and the infection is spread. The pneumococci damage the host by their overwhelming growth and by interfering with lung function.
- Assess resp pattern noting quality, rate
- Place in high semi fowlers position INEFFECTIVE AIRWAY CLEARANCE…r/t retained tracheobronchial secretions secondary to inflammation process
- Assess secretions noting color and consistency and amount
- Encourage incentive spirometer
- Encourage fluids ALTERED BODY TEMPERATURE r/t infectious process
- Assess temp every 4 hours —assess for presence of chills
- Administer Tylenol prn O2 in the acute phase to maintain adequate oxygenation
- Note any trend that indicates worsening status
- Easier to ventilate and oxygenate sitting up
- Note any trend that indicates worsening status —amount or change in color
- Promotes alveolar expansion, which will promote oxygenation
- Will help to liquefy secretions and make them easier to expectorate
- Elevated temp is early response to inflammation /infectious presence. Chills represent rapidly rising temperature.
- Promotes comfort by lowering body
- No pattern of distress
- Oxygenation improved
- Secretions do not have color to them or decrease in frequency
- Oxygenation improves
- Phlegm not as thick
- Temp remains WNL
- Temp decreased
- Encourage oral fluids temperature closer to normal limits.
- In this context, fluids are needed to replace insensible fluid loss due to fever
- Tolerates fluids 5. What body system(s) will you most thoroughly assess based on the primary/priority concern? Respiratory Recognize the clinical relationship of impaired ventilation and neurologic status. As CO2 levels rise, mentation goes from increased confusion/agitation to decreased level of consciousness, which would likely require intubation. We are not there yet, but this correlation needs to be on the radar screen of the nurse as part of needed ongoing assessment. Cardiac The potential for sepsis/septic shock must be anticipated by the nurse with any severe infectious process in a susceptible host. Close assessment of the CV system is a must. This would include close trending of heart rate that would elevate, and BP that trends downward over time. In addition, the presence of diaphoresis, pale cool skin or decreased pulses must also be assessed closely as well. 6. What is the worst possible/most likely complication to anticipate? Respiratory failure resulting in decreased oxygenation that does not respond to increasing O2 amounts. This would likely require intubation. Sepsis/septic shock which could lead to death. 7. What nursing assessment(s) will you need to initiate to identify this complication if it develops? - Respiratory failure o O2 sat that continue to decrease despite placing on Bi-PAP and maximizing settings and delivery of O2-max of 100%. o Increased RR and work of breathing. o Level of consciousness (LOC)—increased lethargy or unresponsiveness — ominous sign that usually reflects increased CO2 levels. - Sepsis/septic shock
Acetaminophen (Tylenol) 1000 mg. oral growth Though a fever is beneficial, depending on the severity and the ability to physiologically tolerate the increased metabolic demands on the body (increased RR, Hr) will dictate if you need to treat this fever Identify infiltrates that would be consistent with pneumonia. Most relevant labs in this panel are WBC, neutrophils, and bands to gauge severity/degree of physiologic response to infection. Hgb is also relevant and must be noted Most relevant labs in this panel are K+ and creatinine to gauge renal involvement if sepsis was present. K+ will be elevated as sepsis progresses because of intracellular leakage of K+ into extracellular space and if renal system takes a hit, K+ will elevate with rising creatinine. Sodium is also relevant and must be noted especially when fluid balance is involved. Lactate is used to identify the presence and progression of sepsis due to its relevance to identify the presence of anaerobic metabolism due to cellular hypoxia as a result of any shock state. Most accurate test to identify key components of adequacy of ventilation by determining the partial pressure of O2, CO2, and pH. Lower body temperature Chest x-ray (CXR) Identify infiltrates if present Complete cell count (CBC) Identify abnormal relevant values and trend day to day Basic metabolic panel (BMP) Identify abnormal relevant values and trend day to day Lactate Lactate <2 if not septic >2 if sepsis is progressing Arterial blood gas (ABG) Expected norms: pH: 7.35-5. pCO2: 35- 45 pO2: > These results may not be
Sputum culture with gram stain Blood culture x 2 sites Urine analysis (UA) Identify specific organism and ensure antibiotics are sensitive to causative organisms. Gram Stain— provides immediate feedback on the type of cell wall to provide a general identification of causative organism. Culture— takes 24 hours for initial screen and then 48 hours for final report of causative organism and what the bacteria are most susceptible to. This will be essential to determine if the infection in the lung has gone systemic and therefore increases the risk for sepsis. Collect specimens from 2 sites to rule out contamination if only 1 specimen bottle comes back positive. Both bottles must be positive for growth in order to have a strong suspicion that infection is present vs. contamination of 1 bottle that can happen in the collection process. Since UTI is a common source of infection in elderly women, this is an easy way to determine if this is present. Though respiratory is the obvious source, it is not unusual to have 2 separate sources of infection in a susceptible host. UA-will provide immediate findings, but this is an excellent example where the nurse must know what data is present but whatever results obtained must be trended closely to determine clinical trajectory Causative organism identified Negative growth if no systemic infection Causative organism identified Negative growth if no systemic infection Expected norms: WBC micro: < LET: negative Nitrates: negative
Davis Drug: rate not to exceed 2 mg/minute therefore this dose should be given over 30 seconds in 0.5 mL increments every 15 seconds Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations : Methylprednisolone (Solumedrol) 125 mg IV push Normal Range: (high/low/avg?) Injectable steroid, it will suppress inflammation that is primarily present in the lungs/bronchioles, which is desirable, but also has an undesirable effect, which is the suppression of the immune system. 2 mL IV Push: Volume every 15 sec? Davis Drug 1- minutes therefore if you choose over 2 minutes will be 0.25 mL increments every 15 seconds *Causes hyperglycemia— monitor glucose levels closely, especially if diabetic *Blunts immune response and WBC count-assess closely for signs of infections or worsening status *Decreases serum K+ levels and increases Na+. Monitor these labs closely *Assess for signs of adrenal insufficiency that can cause hypotension, weight loss, weakness, N&V, confusion, peripheral edema *Monitor I&O and daily weights for signs of adrenal insufficiency Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations : Levofloxacin (Levaquin) 750 mg IVPB (150 mL volume) Normal Range: (high/low/avg?) AVERAGE Inhibits DNA gyrase (bacterial topoisomerase II), an enzyme required for DNA replication, transcription, repair, and recombination 150 mL over 90 minutes Hourly rate IVPB: 225 mL/hour *Obtain any specimen cultures before giving first dose *Assess for allergic response of any kind (rash- itching- hives-anaphylactic- resp distress) *Continue to assess for response to infection and
evaluate response Radiology Reports: What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Results: Clinical Significance: Right lower lobe Infiltrate reflects the consolidation and presence of exudates/secretions infiltrate. caused by the infection/inflammatory process seen in pneumonia. The Hypoventilation hypoventilation is an expected finding in end stage COPD. present in both lung fields Lab Results: What lab results are RELEVANT that must be recognized as clinically significant to the nurse? Complete Blood Count CBC:) Current: High/Low/WNL? Most recent: WBC (4.5-11.0 mm
14.5 HIGH 8.
Hgb (12-16 g/dL) 13.3 WNL 12. Platelets (150-450x 103/μl
217 WNL 298
Neutrophil 92 HIGH 75 Band forms (3-5%) 5 WNL barely! 1 What lab results are RELVEVANT that must be recognized as clinically significant to the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable WBC: 14. Neutrophil: 92% Body is mounting immune response to underlying infection. WBC elevation is due primarily to the increased production of neutrophils, which are the “first responders” of the immune system in response to infection. The elevation of neutrophils in response to a bacterial infection begins as early as 6 hours after the initial insult. This % elevation with the Worsening Worsening…LEFT SHIFT…a clinical red flag
and creatinine are ALWAYS relevant, in this scenario, the following labs must also be noted! CO2: 35 Though not typically relevant, WHY is this lab elevated? In a patient with chronic COPD, the clinical RELATIONSHIP of CO retention, requiring metabolic compensation must be recognized. This same dynamic is also commonly seen on an ABG as well. Serum CO2 measures the amount of available bicarbonate in the blood. Worsening slightly Glucose: 112 This lab is not strongly relevant, but needs to be recognized as not clinically significant. Worsening slightly but not clinically significant especially in the context of physiologic stress where cortisol will be increased and with it higher blood glucose levels BUN: 35 Worsening slightly The relationship of an elevated BUN and a borderline high creatinine must be recognized because they both represent renal function, though BUN is much more indirect. Creatinine: 1. Though creatinine is always relevant, what the nurse must note in this value is that though it is WNL, it is on the HIGH end of normal, and is trending higher than the most recent. This may be significant, so it requires the nurse to closely trend as well Worsening slightly. Because creatinine is a more direct reflector of renal function, this must be assessed closely.
Lactate: 3. as closely assess renal function, I&O’s and urine output. This is the most concerning finding that must be assessed and trended carefully as its elevation is confirming the possibility of SEPSIS…a systemic infection that can be transported through the blood to the entire body. Lactate elevation reflects anaerobic metabolism that is found as sepsis progresses to septic shock due to poor perfusion. No prior level, but in this scenario it does not matter! Any lactate >2 is a red flag that must be recognized. Arterial Blood Gas: Current: High/Low/WNL? pH (7.35-7.45) 7.25 LOW pCO2 (35-45) 68 HIGH PO2 (80-100) 52 LOW HCO3 (24+2) 36 HIGH O2 Sat (>92%) 84% LOW RELEVANT Lab(s): Clinical Significance: pH: 7. pCO2: 68 pO2: 52 Significant metabolic acidosis. This is the first step to interpreting this ABG. The next step is to determine if it is metabolic or respiratory driven. Need to take a look at the CO2 next. This is significantly higher than what you would expect in even a COPD patient with CO2 retention as a baseline. The acidosis is respiratory in origin. Next need to see how she is oxygenating to see if there is a problem. There is a problem! Knowing the range of normal and the clinical data that has been collected, the nurse now has specific data to support the gravity of this clinical situation. The relationship of the pO2 of 52 and this low saturation must be recognized by the nurse. This low sat is expected, but confirms the severity of Joanne’s inability to ventilate adequately, and may be close to requiring bi-pap or even
