Pneumonia-COPD

Joan Walker, 84 years old

Primary Concept

Gas Exchange

Interrelated Concepts (In order of emphasis)

1. Infection

2. Acid-Base Balance

3. Thermoregulation

4. Clinical Judgement

5. Pain

History of Present Problem:

Joan Walker is an 84-year-old female who has had a productive cough of green phlegm

that started four days ago that continues to persist. She was started three days ago on

prednisone 40 mg PO daily and azithromycin (Zithromax) 250 mg PO x5 days by her

clinic physician. Though she has had intermittent chills, she had a fever last night of

102.0 F/38.9 C. She has had more difficulty breathing during the last night and has been

using her albuterol inhale every 1-2 hours with no improvement so she called 9-1-1 and

is brought to the emergency department (ED) where you are the nurse who will be

responsible for her care.

Personal/Social History:

Joan was widowed six months ago after 64 years of marriage and resides in assisted

living. She is a retired elementary school teacher. She called her pastor before coming to

the ED and he has now arrived and came back with the patient. The nurse walked in the

room when the pastor asked Joan if she would like to pray. The patient said to her

pastor, “Yes please, I feel that this may be the beginning of the end for me!”

What data from the histories is RELEVANT and has clinical significance to

the nurse?

RELEVANT Data from Present

Problem

Clinical Significance:

• Productive cough

• Green phlegm

• Condition is Persistent

• Albuterol is not working effectively

• High fever

The patient is presenting with an

infection of the respiratory system, this

needs to be addressed and treated quickly

as it could result in respiratory failure.

RELEVANT Date from Social

History

Clinical Significance

• Lost her husband 6 months ago

• She finds comfort in her pastor

and prayer

• She fears this is the end for her

• Resides in assisted living home

The patient may feel depressed and lonely

since losing her husband. She may also

lose her will to survive if she fears or

believes this is the end for her, this could

cause additional issues and stress.

Patient Care Begins:

Current VS: P-Q-R-S-T Pain Assessment (5th VS):

T: 103.2 F/39.6 C

(oral)

Provoking/Palliative: Deep breath/Shallow breathing

P: 110 (regular) Quality: Ache

R: 30 (labored) Region/Radiation: Generalized over right side of chest

with no radiation

BP: 178/96 Severity: 3/10

O2 sat: 86% 6 liters

n/c

Timing: Intermittent-lasting a few seconds

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