Case study 1 Client Profile Mrs. Harriet is a 68-year-old woman who is alert and oriented. Allergies are Erythromycin. She presents to the emergency department with complaints of chest tightness, shortness of breath, cough, and congestion. She states, “I have been having these symptoms for three days now. I have been taking Maximum Strength Robitussin for my cough but it has not helped very much. When I woke up this morning. I felt very weak so I came in to be checked out.” Her vital signs are blood pressure 110/70, pulse 94, respiratory rate of 28, and temperature of 102.7 F. Her oxygen saturation on room air is 92%. She is placed on 2 liters (L) of oxygen by nasal cannula. The HCP prescribes a 12-lead electrocardiogram (ECG, EKG) and chest X-ray (CXR). Laboratory tests prescribed include complete blood count (CBC), basic metabolic panel (BMP), brain natriuretic peptide (B-type natriuretic peptide assay or BNP), total creatine kinase (CK, CPK), creatine kinase-MB (CPK-MB), and troponin. The HCP will also assess blood cultures x 2, AGs on room air, sputum culture and sensitivity (C &S), and asks that the client have a Mantoux (tuberculin, purified protein derivative, or PPD) test. Case Study Mrs. Harriet’s ECG shows normal sinus rhythm (NSR) with a heart rate of 98 beats per minute. The CXR reveals a right lower lobe(RLL) infiltrate. Laboratory tests include the following results: white blood cell cot (WBC) 12,2000 cells/mm3, 72& seg neutrophils with a left shift of 11% bands, and a BNP of 50.9 pg/mL. ABGs on room air is pH 7.44, partial pressure of carbon dioxide (PaCO2) 39 mmHg, bicarbonate (HCO3) 26.9 mEq/L, partial pressures of oxygen (PaO2) 58 mmHg, and oxygen saturation (SaO2) of 92%. Results of the sputum culture show Streptococcus pneumoniae. The CPK, CPK-MB, and troponin are all within normal limits. Mrs. Harriet is five feet three inches tall and weighs 224 pounds (101.8 kg). On assessment, the nurse hears expiratory wheezes and rhonchi bilaterally with diminished lung sounds in the right base. Her thoracic (chest) expansion is equal but slightly decreased on inspiration. Accessory muscle retraction is not noted, and she does exhibit central cyanosis. The capillary refill of the client’s nail beds is four seconds. Mrs. Harrier is admitted with acute bronchitis and pneumonia. The HCP prescribes oxygen via nasal cannula to keep the client’s saturations greater or equal to 95%, Ceftriaxone sodium, Erythromycin, Albuterol, Acetaminophen every four to six hours as needed, bed rest, an 1800 calorie diet, increased oral (PO) fluid intake to 2 to 4 liters per day, coughing and deep breathing exercises and use of the incentive spirometer (IS). 1. Discuss additional assessment data that would help gain a more thorough understanding or Mrs. Harriet’s symptoms? 2. Discuss the causes, pathophysiology, and symptoms of acute bronchitis? 3. Discuss the pathophysiology and causes of pneumonia in general? 4. Compare the defining characteristics of community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), and viral pneumonia? 5. Discuss the factors that place Mrs. Harriet at greater risk for the development of pneumonia? 6. Mrs. Harriet asks the nurse to explain what the HCP saw on her chest X-ray. She asks, “The doctor said something about a ‘trate’ he saw on my lung, What did he mean by that?” How would the nurse explain what an infiltrate is? 7. Briefly explain the pathophysiology and identify at least five clinical manifestations of the respiratory diagnosis that is being ruled out for Mrs. Harrier by administering the Mantoux test? 8. While awaiting test results to confirm if Mrs. Harriet has TB, what precautions should be taken when assigning her to a room and providing nursing care? 9. Discuss the measurement of induration that would indicate a positive Mantoux test for Mrs. Harrier. If she tested positive for exposure to TB but did not have assessment findings consistent with active disease, what medication could be prescribed, and what is the benefit of this treatment? 10. The nurse asked Mrs. Harriet if she has been using her incentive spirometer. Mrs. Harriet states, “I tried to use it a couple of times but I think it is broken. When I blow into it, the ball does not go up like I was told it should.” How should the nurse intervene? 11. Briefly discuss the significance of each of the following laboratory results: (a) WBC 12,200 (b) 72%seg neutrophils, (c) left shift of 11% bands, (d) BNP 50.9 (e) results of sputum culture show S. Pneumoniae, (f) CPK WNL, (g) CPK-MB WNL, and (h) troponin WNL 12. Analyze Mrs. Harriet’s ABG results. Determine whether each value is high low or within normal limits: interpret the acid-base balance; determine if there is compensation, and indicate whether the client has hypoxemia. 13. The nurse calls the HCP to request a change in the medications that have been prescribed for Mrs. Harriet. Discuss which medication the nurse is concerned about being unsafe for this client. 14. Provide a rationale for each of the following prescribed components of Mrs. Harriets treatment plan: oxygen to keep the client’s oxygen saturation greater than or equal to 95%, Ceftriaxone sodium, Albuterol, Acetaminophen, bed rest, 1800 calorie diet, increased oral (PO) fluid intake to 2 to 4 liters per day, coughing and deep breathing exercises and use of the incentive spirometer (IS). 15. Mrs. Harriet was taking Dextromethorphan at home to help manage her cough. The HCP did not prescribe continued use of the Dextromethorphan during hospitalization. Explain this omission. 16. If it was learned that Mrs. Harriet has a past medical history of chronic obstructive lung disease (COPD), how would the HCP’s prescription that oxygen is delivered to keep the client’s oxygen saturation greater than or equal to 95% be changed? 17. Identify three priority nursing diagnoses that should be included in Mrs. Harriet’s plan of care. 18. You are the nurse providing discharge teaching to Mrs. Harriet. Briefly discuss what you will recommend to her regarding seeking follow-up care, lifestyle considerations, and how to help prevent Pneumonia in the future.