HESI Case Studies – COPD w/ Pneumonia
62M comes to ED w/a 4 day history of increased sputum production, change in character of sputum, increased SOB, and fever 101F. History of smoking 2packs/day prior, beginning at age 14. He reports he had asthma as a child and he’s been treated with Albuterol inhalers as an adult. Has been hospitalized 2x w/pneumonia; the most recent was 2 years ago.
VS: 101F, P 115, R 30, BP 120/80
Respirations shallow and labored, w/use of accessory muscles
Increased AP diameter of chest
Skin dry and warm touch, inelastic skin turgor, fingernail clubbing.
Which assessment is most important for nurse to complete next?
Auscultate breath sounds
Rationale: This is the highest priority because Mr. Johnson is clearly exhibiting respiratory distress
Which assessment finding supports pt’s diagnosis of pneumonia
Pulse of 115– tachycardia is most consistent w/infectious process, in addition pt’s fever and rapid RR are also VS findings that indicate a problem–> infection
Rationale: Tachycardia is consistent with an infectious process. In addition, Mr. Johnson’s fever and rapid respiratory rate are also vital sign findings that indicate a problem, such as an infection.
These ABG results indicate that pt is experiencing which acid-base imbalance
Rationale: The low pH indicates that acidosis is present. The elevated pCO2 indicates that the problem is respiratory in nature. Clients w/any condition that depresses respirations are prone to the development of respiratory acidosis. Even though pt has a rapid RR, his underlying COPD causes retention of CO2
Which nursing diagnosis has the highest priority when the nurse is planning care for pt?
Ineffective airway clearance–
There are adventitious breath sounds, tachypnea, changes in depth of respirations, fever, and cough, all of which support this as a priority diagnosis.
Pt admitted and HCP prescribes:
-Bedrest w/bedside commode
-O2 at 2L/min nasal cannula
-diet as tolerated
-continuous O2 sat monitoring via pulse oximeter
-IV fluid 5%Dextrose and 0.45% NS at 3L/day
-obtain sputum culture
-ampicillin 1gm IVPB Q6H
-Neb Tx Q4H and prn saline & albuterol
– beclomethasone inhaler 2puffs 2x/day
-albuterol 2puffs 4x/day
methylprednisolone 125mg IVPB Q8H
Which nursing action should be implemented before Ampicillin is administered?
Obtain sputum culture–
the sputum culture will be compromised if broad-spectrum is taken first. The sputum specimen should
Ampicillin 1 gm IVPB is supplied in 50mL of D5W to be delivered over 30minutes. Nurse should set the IV pump at how many mL/hr?
Which assessment is most important for nurse to perform while pt is receiving albuterol?
Monitor pulse and BP–
it’s a beta adrenergic agonist. B/c replicates sympathetic stimulation, pt should be monitored for arrhythmia, HTN, nervousness and restlessness
Nurse observes pt as he uses his inhalers. Using the spacer, pt takes 2 puffs of albuterol, followed a minute later by 2 puffs of the beclomethasone. After observing pt, the nurse should initiate what teaching?
“Wait at least 1 minute between each puff of the same med”– wait 5 minutes before using the second med
Which instruction should nurse provide pt for an acute episode of asthma?
“Use Ventolin inhaler for acute asthma attacks”– albuterol is a bronchodilator for acute asthmatic attacks
Continuous monitoring of pt’s O2 sat indicates readings between 90-91 (normal O2 sat values are 90-100).
After checking the sensor site to make sure the readings are accurate, the nurse should then initiate which intervention?
Elevate the head of bed to high-Fowler’s position–
semi to high-Fowler’s positions decrease the pressure on diaphragm and allow from improved lung expansion. Pt’s w/COPD prefer to lean forward and rest in tripod
Which action should the nurse implement to ensure accurate O2 sat readings via pulse oximeter?
Assess adequacy of circulation prior to applying the sensor–
move the sensor to new site at regular intervals
Pt scowls and complains that his breakfast is cold, his family has not yet been to visit him, and it was so noisy during the nigh he was unable to sleep. The nurse recognizes he may displacing his anger as a defense mechanism.
What is the best statement for the nurse to use to promote effective communication?
“you seem pretty upset this morning”–
allows for communication
In response to nurse, pt explains “it seems like I’ve been sick so much. It’s all the fault of those cigarette companies. I wouldn’t be so sick if they had warned us about the dangers of smoking. I’ll probably end up with cancer, and then I’ll sue them.”
What’s nurse’s best response?
Later the UAP helps pt transfer from bedside–> commode. After pt is back in bed, nurse enters room and observes O2 sat is 85% and he’s not wearing nasal cannula. He states that the tubing wouldn’t reach to the commode so UAP removed it.
What is best nursing action
Instruct the UAP involved regarding the inappropriate removal of the nasal cannula–
Helping pt to commode is appropriate action for UAP to perform, but the UAP requires some add’l instruction and individual supervision
The Nat’l Council of State Boards of Nursing has defined 5 rights of delegation.
Which one of these rights was violated in this situation
Since continuous O2 was a high priority, the nurse’s directions to the UAP should have emphasized the nasal cannula to be left on at all times, especially during activity. the Right Supervision includes direction/guidance, eval/monitoring and follow-up
Pt O2 sat returns to 91% after nasal cannula. Remainder is uneventful. VS: 99F, P84, R 22, BP 130/78. Lung sounds are diminished, crackles less audible, and pt is producing only min clear sputum. During night pt calls nurse cannot catch his breath. Upon assessment, the nurse notes pt’s RR has increased to 40 w/dyspnea. O2 sat is 55, Pulse is 110, weak and thread and BP 70/40
Which intervention should the nurse initiate immediately?
Place resuscitation equipment in the room–
This is priority b/c pt’s sat is dangerously low. Nurse should prepared to transfer him to CCU
Pt’s condition improves, son expresses concern that pt will continue to smoke. Son asks nurse if anti-smoke hypnosis tapes could be played during the night while pt sleeps.
Which ethical principle is most important for the nurse to consider when responding to son?
the ethical principle refers to the individual’s right to make own decisions. Consent
The remainder of pt’s hospital stay is uneventful. Which outcome statement is best indicator that pt’s pneumonia is resolved and he is ready to be discharged?
Sputum culture is negative — SIGNIFICANT
Pt, his son, nurse discuss use of anti-smoking hypnosis tapes, along with other measures to promote good health upon his discharge. Pt agrees to follow all of the d/c instructions and states that he understands use of meds, including the correct use of metered dose inhaler.
Which add’l d/c instruction(s) should the nurse include in teaching plan to promote optimal health for pt?
– avoid crowds and people w/infections– and pneumovax
– store prescribed inhalers away from extreme heat & cold– extreme alterations can alter inhaler meds and render it ineffective