Lecture on Nursing Case Study: COPD and Pneumonia

Introduction

• Case studies as powerful educational tools for practice-based professions such as nursing.
• Focus on critical thinking and clinical reasoning to prepare students for practice and NCLEX.

Patient Introduction: Joan Walker

• 84-year-old female
• Symptoms: productive cough with green phlegm (4 days), intermittent chills, fever (102°F last night), difficulty breathing, frequent use of albuterol inhaler (1-2 hours with no improvement).
• Medication: Prednisone 40 mg daily, Azithromycin 250 mg daily.

Initial Assessment and Vital Signs

• Age: 84 (higher risk for complications)
• Symptom Significance:
  • Green phlegm: Indicative of infection.
  • Medication: Prednisone (reduces inflammation), Azithromycin (antibiotic).
  • Fever and chills indicate inflammatory response.
  • Frequent use of albuterol with no improvement suggests severe respiratory distress.
• Vital Signs:
  • Temperature: 103.2°F
  • Pulse: 110 bpm
  • Respiratory rate: 30/min
  • Blood pressure: 178/96 mmHg
  • O2 saturation: 86% on 6L nasal cannula

Nursing Assessment

• General Appearance: Anxious, distressed.
• Chest: Barrel chest (chronic COPD), accessory muscle use, diminished breath sounds with expiratory wheezing.
• Skin: Pale, hot, dry.
• Other: Alert and oriented, abdominal non-tender, skin integrity intact.

Diagnostic Data

• Basic Metabolic Panel:
  • Sodium: 138
  • Potassium: 3.9
  • Glucose: 112
  • Creatinine: 1.2
• Complete Blood Count (CBC):
  • White Count: 14.5 (high, indicates infection)
  • Hemoglobin: 13.3
  • Platelets: 217
  • Neutrophils: 92% (high, indicates infection)
  • Bands: 5% (left shift, indicates severe infection)
• Lactate: 3.2 (elevated, indicates lactic acidosis)
• ABG (Arterial Blood Gas):
  • pH: 7.25
  • pCO2: 68
  • pO2: 52
  • Bicarbonate: 36
  • O2 saturation: 84%
• Chest X-ray: Left lower lobe infiltrate, hypoventilation present in both lung fields.

Clinical Reasoning Process

1. Primary Problem: Pneumonia with possible sepsis.
2. Medical Plan of Care:

• Medications: Albuterol nebulizer, IV lorazepam, methylprednisolone, levofloxacin, Tylenol.
  • Understand mechanisms: Beta-2 agonist (albuterol) dilates bronchioles, methylprednisolone reduces inflammation.

3. Nursing Priority: Impaired gas exchange, respiratory distress, potential sepsis.

• Increase oxygenation, administer medications, monitor vitals, provide supportive care.

4. Psychosocial and Holistic Care: Address anxiety, provide comfort, be intentional with communication, consider spiritual needs.
5. Education and Discharge Priorities: Teach about medications, oxygen use, infection signs, and follow-up care.

Conclusion

• Importance of understanding patient needs and clinical reasoning.
• Encourage sharing of strategies for teaching critical content.
• Resources available for additional learning and active teaching strategies.

Action Items:

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