Nursing Case Study for Pneumonia
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Outline
Charles is a 72-year-old male patient admitted via the emergency department to the medical surgical floor at 2220 with a diagnosis of community acquired pneumonia (CAP). He arrives in the room via stretcher with oxygen (O2) via nasal cannula (NC) and is able to transfer to the bed with minimal assistance. He does get short of breath (SOB) with exertion.
What assessment findings does the nurse expect for this patient? Should there be a particular focus to the assessment?
Are there any ER results the nurse should ask about during the bedside report?
What orders does the nurse expect the admitting provider to give?
After screening and assessing the patient, the nurse has the following data:
Patient AA&Ox4. SOB noted with speaking and after he moves around. IV 20g noted in left arm. Productive cough with moderate sputum production occasionally. Lung sounds in all fields indicate crackles; no barrel chest noted. Skin is warm and dry. He voids per urinal no assistance needed. Verbalizes understanding of call light use.
BP 120/60 SpO2 93% on NC 2L
HR 100 bpm and regular Ht 172 cm
RR 18 bpm Wt 60 kg
Temp 38.3°C
CXR – posteroanterior and lateral chest radiographs obtained (two view). Radiographic findings consistent with the diagnosis of CAP including minor lobar consolidations, moderate interstitial infiltrates
CBC (abnormal/significant only listed, if NOT listed then the value falls within expected limits or is not significant for this patient), for reference see nursing.com Lab Value cheat sheet:
WBC 15,000 cells/mcL
Bands 10%
Neutrophils 60%
Eosinophils 1%
Basophils 1%
Lymphocytes 20%
Prioritize the top nursing interventions.
What should the nurse be on the lookout for as the shift progresses? What warrants a call to the provider?
Are there other orders the nurse might anticipate and/or suggest?
Are there past medical history concerns specific to this patient and his background that may aid in the plan of care?
ABG values:
pH 7.30
PaCO2 50 mmHg
HCO3- 23 mEq/L
PaO2 88 mmHg
What does this ABG indicate? How do you know? What may have caused this value? What can you do?
The nurse gets the CNA to assist and repositions Charles in his hospital bed and he now sits straight but comfortably up in bed with pillows to bolster him. A yankauer at the bedside that he can use for a productive cough allows him to clear his airway after a brief teaching session. He had been frequently removing his NC due to ear discomfort, so RT brought padding for the tubing and Charles reports improved comfort. RT and the nurse teach him about “turn, cough, deep breath” aka TCDB.
After sleeping on and off through the shift, Charles is able to consume approximately 75% of his breakfast. He can properly demonstrate use of his IS and TCDB techniques. His NC remains in place with the padding on ears and his O2 sat is 95% on 2 L. He has two functioning IVs, one in each arm. Physician rounds and advises to continue plan of care including medication regimen based on test results after he and nurse discuss patient during rounds with the clinical pharmacist.
Describe examples of interdisciplinary team collaboration that may be useful in this patient’s care.
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Transcript
Hi everyone. My name is Abby. We’re going to go through a case study for pneumonia together. Let’s get started in this scenario. We have a 72-year-old patient who is male. He was admitted via the emergency department to the med-surg floor with a diagnosis of community-acquired pneumonia. He arrives in the room by a stretcher with oxygen flowing through a nasal cannula. He is able to transfer to the bed with minimal assistance. However, he does get short of breath with that exertion. Having this information, let’s go ahead and take a look at critical thinking checks number one, two, and three below.
Great job! After screening and assessing the patient, the nurse has the following data:
The patient is alert and oriented times four, and he’s still exhibiting shortness of breath when he speaks or with exertion. He has an IV that’s a 20 gauge in his left arm. He has a productive cough that produces moderate sputum. His lungs have crackles in all fields, but no barrel chest is noted. His skin is warm and dry, and he’s able to void into a urinal without assistance. He verbalizes understanding the use of his call light. Additionally, a chest x-ray was ordered in all views. The chest x-ray showed minor lobar consolidation, which is when the alveoli are being filled with fluid, consistent with pneumonia, as well as moderate interstitial infiltrates. This is when scarring and inflammation takes place in the tissue surrounding the alveoli capillaries. Both of these are visualized on x-ray. Now that we have some of this information, let’s go ahead and take a look at our vitals and lab results.
All right. Let’s take a look at those vitals. The vital signs are as follows:
His blood pressure is 120/60 mmHg on those two liters that we talked about via the nasal cannula. He’s saturating at 93%. His heart rate is 100 beats per minute, a respiratory rate of 18 beats per minute, with a temperature coming in at 38.3 degrees Celsius. Let’s take a look at the labs on the CBC:
It’s broken down into the markers that indicate inflammation. His white blood cells are 15,000, bands are 10%, that’s immature neutrophils. Neutrophils are 60% definitely elevated. Eosinophils are 1%, Basophils are 1% and lymphocytes are 20%. Now that we have all of these results, let’s take a look at our critical thinking checks. You’re going to go through numbers 4, 5, 6, and 7 below.
Excellent work! We also got an ABG with this patient, our arterial blood gas. Let’s take a look:
The pH is 7.30 with a PaCO2 of 50, a little elevated, a bicarbonate of 23 and a PaO2 of 88. Now that we have this information, let’s go ahead and take a look at our critical thinking check number eight.
Great job. The nurse gets a CNA to assist her in repositioning Charles in his hospital bed. Now he’s sitting up straight and is nice and comfortable with pillows to bolster him at the bedside. There’s a yankauer . He uses this. When he coughs, when there’s productive sputum, he can clear his airway. The nurse teaches him how to use it. He had been frequently removing his nasal cannula because of the discomfort from the tubing. So, respiratory therapy brought padding for the tubing and Charles reports that it indeed increases the comfort. Respiratory therapy and the nurse teach him about “turn, cough, and deep breathe”. You might see this abbreviated as TCDB. After sleeping on and off throughout the shift, Charles is able to consume about 75% of his breakfast. He properly demonstrates the use of his incentive spirometer and is indeed turning, coughing and deep breathing. His nasal cannula remains in place now that he has the padding and he’s satting at 95% on those 2L by a nasal cannula. He has two functioning IVs, one in each arm. The physician, the clinical pharmacist, and the nurse round and decide to continue the plan of care, including the medication regimen that was devised based on test results. Now that we have all of this information, let’s take a look at our critical thinking check number nine below.
Great job guys. That wraps up our case study on pneumonia. Please take a look at the attached study tools and test your knowledge with a practice quiz. We love you guys, now go out and be your best self today, and as always happy nursing!
References:
For condition from uptodate.com Clinical evaluation and diagnostic testing for community-acquired pneumonia in adults
Author:Michael Klompas, MD, MPHSection Editor:Julio A Ramirez, MD, FACP (last updated June, 2021) AND Overview of community-acquired pneumonia in adults
Author:Julio A Ramirez, MD, FACPSection Editor:Thomas M File, Jr, MD (last updated Sept, 2021)
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