Question

Scenario

H.K.’s sister has brought her 71-year-old brother to the primary care clinic because he has had a fever for 2 days. She says he has shaking chills and a productive cough and he cannot lie down to sleep because “he can’t stop coughing.” After H.K. is examined, he is diagnosed with community-acquired pneumonia (CAP) and admitted to your floor at 1130. The resident is busy and asks you to complete your routine admission assessment and call her with your findings.

Name 4 priority areas to include in your assessment.
CASE STUDY PROGRESS
Your assessment findings are as follows: H.K.’s vital signs (VS) are 154/82, 105, 32, 103° F (39.4 ° C), Spo₂ 84% on room air. You auscultate decreased breath sounds and coarse crackles in the left lower lobe anteriorly and posteriorly. His nail beds are dusky on fingers and toes. He has cough productive of rust-colored sputum and complains of pain in the left side of his chest when he coughs. He is a lifetime nonsmoker. His medical history includes coronary artery disease and myocardial infarction with a stent. He is currently on metoprolol, amlodipine, lisinopril, and furosemide; for his type 2 diabetes mellitus, he is taking metformin and glipizide. He has never gotten a pneumococcal or flu vaccination. He does report getting “hives” when he took “an antibiotic pill” a few years ago but does not remember the name of the antibiotic.

Which assessment findings are significant? Give your rationale.

Admission Orders
Consistent carbohydrate diet
VS q2h
IV of D₅ ½NS at 125 mL/hr
Ceftriaxone 1gram IV every 12 hours
Albuterol 2.5 mg/ipratropium 250 mcg nebulizer treatment STAT, then q4h
Titrate O₂ to maintain Spo₂ over 90%
Obtain sputum for C&S
STAT blood cultures & sensitivity
Blood glucose ac and hs with sliding scale regular insulin per protocol #2
CBC with differential and basic metabolic panel
CXR now and in the morning
Continue home medications

You obtain orders from the resident. Outline a plan of what you need to do in the next 2 to 3 hours.

Is D₅½NS an appropriate IV fluid for H.K.? State your rationale.

What is the rationale for ordering O₂to maintain Spo₂over 90%?

What is a C&S test, and what role will blood and sputum cultures play in H.K.’s care?

What would you expect the CXR results to reveal?

You need to follow a specific protocol when obtaining peripheral blood cultures. Place in order the steps you will perform.

_____ 1. Select venipuncture site. Cleanse and allow to dry.
_____ 2. Inject 10 mL of blood into the aerobic bottle.
_____ 3. Perform venipuncture and collect 20 mL of venous blood.
_____ 4. Verify patient’s identity and perform hand hygiene.
_____ 5. Attach identification to specimens and send to laboratory within 30 minutes.
_____ 6. Inject 10 mL of blood into the anaerobic bottle

The pharmacy sends the ceftriaxone in 100 mL 0.9% NaCl with instructions to infuse over 40 minutes. At how many milliliters per hour will you regulate the IV infusion pump?

How will you ensure H.K.’s home medication list is accurate?
CASE STUDY PROGRESS
The next morning you are again assigned to care for H.K. Your assessment findings are as follows: VS 154/82, 92, 26, 100° F (37.8° C), Spo₂ 94% on 2 L O₂ per nasal cannula. He appears to be in no apparent distress and denies any dyspnea. You auscultate decreased breath sounds and coarse crackles in the left lower lobe anteriorly. His skin is pale, warm, and dry. He has a cough productive of yellow-colored sputum and complains of pain in the left side of his chest when he coughs.

Is H.K. recovering as expected? Explain your rationale.

Based on your evaluation of H.K., write an outcome to achieve by the end of your shift, then list 6 priority interventions you will perform toward achieving this goal.

By the end of your shift, which assessment findings would bestindicate that H.K. is responding to therapy?
CASE STUDY PROGRESS
After continuing the plan of care for 2 more days, H.K. is recovering from his pneumonia and preparing for discharge.

You know that H.K. is at increased risk for contracting another CAP infection. Describe 4 strategies for preventing CAP infections you will include in H.K.’s discharge teaching plan.

Obtain a pneumococcal vaccine boosters and yearly influenza vaccines

Avoid exposure to people with colds or flu and crowds during flu season

Perform good hand washing

Properly dispose of secretions

Maintain oral fluid intake sufficient to thin secretions and facilitate expectoration

H.K. confides in you, “You know, my wife died a year ago, and I live alone now. I’ve been thinking . . . this pneumonia stuff has been a little scary.” How will you respond?

What are some community resources from which H.K. may benefit?
CASE STUDY OUTCOME
H.K. is discharged in the company of his sister. His plan is to stay with her for a few days. He thanks you for your care and taking the time to listen and talk with him. He says his sister and he talked, and they intend to join the local senior center after he is feeling better.

Answer 1

#. Assessment includes :-

Assess respiratory symptoms. Symptoms of fever, chills, or night sweats in a patient should be reported immediately to the nurse as these can be signs of bacterial pneumonia.

Assess clinical manifestations. Respiratory assessment should further identify clinical manifestations such as pleuritic pain, bradycardia, tachypnea, and fatigue, use of accessory muscles for breathing, coughing, and purulent sputum.

Physical assessment. Assess the changes in temperature and pulse; amount, odor, and color of secretions; frequency and severity of cough; degree of tachypnea or shortness of breath; and changes in the chest x-ray findings.

Assessment in elderly patients. Assess elderly patients for altered mental status, dehydration, unusual behavior, excessive fatigue, and concomitant heart failure.

#. The assessment findings which are important are :-

Vital signs (VS) are 154/82, 105, 32, 103° F (39.4° C), Spo2 84% on room air.

Decreased breath sounds and coarse crackles in the left lower lobe anteriorly and posteriorly.

Nail beds are dusky on fingers and toes.

Productive cough of rust-colored sputum

Pain in the left side of his chest when he coughs.

#. Plan for the next 2-3 hrs :-

- Vital assessment , chest X-ray

- Oxygen administration

- IV fluid administration

- Obtaining blood and sputum culture

- Administration of prescribed medication

- Blood glucose monitoring and insulin administration as per sliding scale

- Diet consultation

#. Sodium plays a bigger part in determining your osmolality than glucose. That's why D5 1⁄2 NS is not an isotonic solution. As such, D5 1⁄2 NS is NOT appropriate for most medical patients who are hypovolemic. The hypovolemic patient (e.g. patient with sepsis, pneumonia, intractable nausea/vomiting, etc)