Did you know that case studies remain one of the most powerful tools an educator has to teach a practice-based profession such as nursing? Today I will share a skinny reasoning case study on COPD pneumonia that is brief and can be completed in just 15 to 20 minutes and emphasizes both critical thinking and clinical reasoning so students are better prepared for practice and the NCLEX. So let's get started. Joan Walker is an 84 year old female who has had a productive cough of green phlegm that started four days ago that persists She was started three days ago on prednisone 40 milligrams daily and azithromycin 250 milligrams daily for five days by her primary physician Though she has had intermittent chills.
She had a fever last night of 102 degrees She has had more difficulty breathing during the night and has been using her albuterol inhaler every one to two hours with no improvements. So she called 911 and was brought to the emergency department where you are the nurse who will be responsible for her care. Now again, a key tenant of clinical re-insane is the ability to recognize. relevant clinical data step by step as we work through this scenario so as the nurse in the emergency department gets this initial scenario in this initial report what's relevant and why well as we look at this she's 84 years old Joan is old therefore she is at higher risk and is a right patient who could develop a problem or complication she's had green phlegm what is the significance of common color to phlegm versus clear or white. Dead neutrophils.
She has an infection. Yellow or green or anything in between is always a red flag that needs to again be recognized as relevant by the nurse. She was started on prednisone, azithromycin.
The nurse must understand what are these drugs doing? One is decreasing inflammation. She's got the history of COPD. What is that relationship between COPD as as it relates to inflammation and breathing? She's also had intermittent chills and a fever of 102 degrees.
This contextualizes the importance of the inflammatory response and recognizing that there is something cooking and it's not dinner. So now she's been more short of breath, using her albuterol inhaler every one to two hours with no improvement. So she called 911. All of that data is definitely recognizing or stating there is a problem, and the nurse needs to recognize this is a very high-risk, critical patient. So let's move on. The nurse collects the first set of vital signs.
The temp is 103.2. The pulse is 110. Her respiratory rate is 30. Her blood pressure is 178 over 96 and her O2 sets are 86% on 6 liters per nasal cannula. And again, step back. What is relevant and why is it significant? Well, we have got, again, our febrile response is even higher.
we have got a full-blown inflammatory response, most likely due to an infection. Her pulse is 110, her rate is 30. Those first three vital signs criteria are the components of SIRS criteria. Recognize that there is a systemic inflammatory response that is more than just a simple pneumonia.
She's likely septic. Blood pressure is high, though, at this point in time, and is not trending low as we would expect with septic shock. And our O2 stats, 86%.
Yes, 92% or greater. 90% with a history of COPD or pneumonia. That's too low.
Six liters, can we go to eight or 10 nasal cannula? No. The nurse needs to recognize we basically need to go to an alternative oxygen delivery system, such as a face mask or a high-flow nasal cannula. Let's now go to the nursing assessment. Her general appearance, she's anxious and distressed, barrel chest present.
Her respirations, she's dyspneic with accessory muscle use. Her breath sounds are diminished bilaterally with anterior-posterior expiratory wheezing. She's pale, hot, and dry. She's got equal with pulses.
Bilaterally, she's alert and oriented times four. Her abdomen soft, non-tender, voiding without difficulty, urine clear yellow, skin integrity intact. And again, what's relevant and why in this physical assessment, a very brief head to toe in the context of this patient. She's got the barrel chest. What does that signify?
She has chronic COPD. She's using her accessory muscles. What's the significance of retractions? The nurse must be able to see. Let's recognize that's always a patient who is struggling and in distress.
They're by there, she's diminished and she's got expiratory wheezing. What does that signify? And what's the physiologic significance of wheezing?
Again, narrowed bronchioles causing that whistling. She's tight and she needs to be opened up. So let's go to the next. we get some laps. And here's our diagnostic data, her basic metabolic panel.
Her sodium is 138, K is 3.9, her glucose is 112, her creat is 1.2. Compared to her most recent, there's not a trend. Again, a key component of clinical reasoning, where's our trend? Where's our trajectory going? Comparing the most recent, whether it was a week ago, a month ago, or a year ago, or just four hours ago, if they're in the acute care setting or any care setting, no problems there.
White count. Let's look at our... CBC white count is currently 14.5 hemoglobin 13.3 platelets 217 92% neutrophils with five bands again look at her most recent look at where our trends going our white count is too high and contextualizing that we have a full-blown inflammatory response with an aggressive neutrophil count percentage of 92% again that's high she's left shifting with positive bands which are immature neutrophils All of these aspects of the significance in a white blood count need to be recognized by the nurse.
Let's look at her lactate, 3.2. Normal is less than 2.2. What's the significance of lactate?
Well, when your students know their physiology, they can go back and say, what happens when you have cells that are not getting enough oxygen? We call that lactation. lactic acidosis or anaerobic metabolism.
Therefore, when you have perfusion issues, you have a lactate that's gonna be elevated. That's why lactate needs to be recognized as a red flag anytime it's present, but when it's elevated, again, we have a problem. Let's look at her ABGs.
Her pH is 7.25. Her PCO2 is 68. Her PO2 is 52. Her bicarb is 36. And her O2 stats are 84%. We need to look at each aspect of what's taking place here.
Why is she acidotic? Well, let's look at her CO2. She's definitely driving that down.
She's got respiratory acidosis, but she's also hypoxic. 52% is too low. 80 to 100 is normal if you know your ABGs. And O2 sat is, again, 84%. Bicarb is 36. That's way high.
Why? Well, the nurse can make a judgment knowing that she's a COPD-er. She's got chronic CO2 retention. Therefore, her kidneys are compensating with the bicarb.
Again, these key constructs need to be deeply understood by our students who will soon be nurses. And now let's look at the chest X-ray. left lower lobe infiltrate, hypoventilation present in both lung fields. And again, that's confirming an infiltrate consistent with pneumonia. Now again, do we need an x-ray to tell us she has pneumonia and has got respiratory distress?
No, we've interpreted the data using Christine Tanner's model of clinical judgment. We've interpreted it correctly as a thinking nurse and we have a problem that's pneumonia. The x-ray is just confirming that. So that's the first half of skinny reasoning.
It's asking what's relevant and why and that's a key construct of clinical Reasoning so now let's go deeper and we're just going to ask five simple Questions that will can that will grasp the essence of clinical reasoning and making it practical question number one After interpreting relevant clinical data, what is the primary problem? And then state the pathophysiology of this problem in your own words. Well, it's obvious we have pneumonia is present, but do we have something more than pneumonia?
Yes. We need to recognize pneumonia superimposed with a patient who meets SIRS criteria or that systemic inflammatory response syndrome. That is a problem that could deteriorate quickly if we're not anticipating and being proactive with our thinking.
Secondly, state the rationale and expected outcomes for the medical plan of care. And again, the nurse must understand the physician and the medical model and why would they order these medications. like a duoneb of albuterol, apatropium nebulizer.
Establish the peripheral IV. Lorazepam, one milligram. Methylprednisolone IV push. Levofloxacin, 750 milligrams, as well as Tylenol, 1,000 milligrams.
We want our students to know the mechanism of action. How is albuterol and apatropium nebulizer gonna benefit this patient? Again, the nurse... We must understand beta-2 agonist, that it's going to dilate by addressing the sympathetic nervous system and therefore improve oxygenation.
It's going to be a bronchodilator as we do that beta-2 stimulation. And therefore, just working through that, we want our students to know the mech of action of every aspect of these medications. And then let's go to the nursing priority, question number three. What nursing priority will guide your plan of care? And this is where we need to give our students the flexibility to say NANDA when it fits and state the essence of which is, again, a construct of clinical reasoning when it does not.
Now, I can go with NANDA in this context of impaired gas exchange. clearly, as well as respiratory distress, but we also have some other issues related to sepsis and looking at those aspects. But in essence, we have an oxygenation issue.
And therefore, we wanna use that as our primary focus. The ABCs are always relevant. And so we have a B priority, but that sepsis is also a, not currently a B priority, but it's going to be at best a C priority.
But again, they are dovetailing. We need to have both of those on our radar. And then the interventions that we're going to do to manage oxygenation, whether it's going to be increase our oxygenation flow, whether it's going to be sitting that patient upright, administering those medications like the Duoneb, all of that's part of the nurse's plan of care.
Then we go to four, psychosocial and holistic care priorities that need to be addressed. And again, we want our nurses to not only think like a nurse, but to care like a nurse. So we want them to see the big picture of the art of nursing and say, what is this patient going through? If you couldn't breathe. How would you feel?
Would you be anxious? Would you feel like you might be stressed? And just how would you want to be comforted? Again, using touch and other aspects of communicating caring.
We need to be very intentional. We need to address these aspects of the art of nursing, even spiritual care in the context of a patient who is in distress. She's not currently dying, but she may want that to provide additional comfort if that's important to her.
And finally, what educational and discharge priorities need to be addressed to promote health and wellness for this patient and or family. We're not going to be addressing this right now in the emergency department with a patient with a BC priority, but when this patient gets admitted and is on the floor and is now day two or day three and is going to go home in the next one to two days, this must be on our radar as nurses and be very intentional to help. communicate what that patient needs to know regarding education.
But I would also go on to say that if you're in the emergency department or any acute care setting that you've got a critical patient or potential, teach them as you're communicating to them what you're doing, why you're doing it, why we're giving this nebulizer, why we're giving this IV, and all that we're doing, that's going to communicate caring. It's also going to provide comfort. So never just remember there's a patient there.
who's very stressed and anxious, don't ignore that, but always be teaching everything the nurse does. And that truly is the essence of providing that holistic care that's going to make our patients be comfortable and feel cared for. What did you think? I think that you can do this and you can do this in your classroom.
But as you look at this, what is your go-to strategy to help your students understand important content in your classroom? I'd like to hear what you do. So post a comment on this video and let others learn from your journey.
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