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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