COPD with Pneumonia

COPD with Pneumonia Meet the Client: Darrel Johnson Darrell Johnson is a 62-year-old who comes to the Emergency Room with a 4day history of increased sputum production, a change in the character of sputum, increased shortness of breath, and a fever of 101° F. He has a smoking history of 2 packs a day for the past 20 years, and he smoked 1 pack a day prior to that beginning at the age of 14. He reports that he had asthma as a child, and that he has been treated with Albuterol inhalers from time to time as an adult. Mr. Johnson has been hospitalized twice with pneumonia, most recently 2 years ago. Instructions: While taking this case study, all questions must be answered correctly before you will be able to proceed to the next page. For all incorrect answers, select a new response and click the Next button. When all questions have been answered correctly, clicking the Next button will display the next page. Page 1 1. Assessment Physical exam reveals the following: o Vital signs: T 101° F, P 115, R 30, BP 120/80. o Respirations shallow and labored, with use of respiratory accessory muscles. o Increased anteroposterior (AP) diameter of the chest. o Skin dry and warm to touch, with inelastic skin turgor, and fingernail clubbing present. 2. 1. Which assessment is most important for the nurse to complete next? A. Auscultate breath sounds. Correct This is the highest priority, since Mr. Johnson is clearly exhibiting respiratory distress. B. Determine pupillary response to light. This is not a priority at this time. C. Observe for jugular vein distention. This gives information about fluid volume overload. Because of his fever, warm skin, and inelastic skin turgor, Mr. Johnson is more likely experiencing fluid volume deficit. D. Palpate pedal pulses. Although this provides valuable information about over all circulatory function, it is not the highest priority. 2 2. Which assessment finding supports Mr. Johnson's diagnosis of pneumonia? A. Pulse rate of 115. Correct Tachycardia is consistent with an infectious process. In addition, Mr. Johnson's fever and rapid respiratory rate are also vital sign findings that indicate a problem, such as an infection. B. BP of 120/80. This is a normal finding. C. Increased AP diameter of the chest. This finding is typical in clients with emphysema, but it is not an indicator of pneumonia. D. Fingernail clubbing. Clubbing of the fingernails is an indicator of chronic lung disease, such as chronic asthma or emphysema, but it is not an indicator of an acute infectious process, such as pneumonia. 3 The nurse auscultates crackles bilaterally in the lower posterior lung fields, with diminished breath sounds noted throughout all lung fields. Mr. Johnson's chest x-ray shows infiltrate in the lung bases bilaterally. Mr. Johnson is admitted to the acute care facility with a medical diagnoses of COPD pneumonia and is transported to the nursing unit. Page 2 1. Arterial Blood Gas (ABG) Analysis Arterial Blood Gases were obtained with the following results: 2. o pH 7.28. o o o pCO2 55. HCO3 25. pO2 89. 3. Based on these ABG results, which acid base imbalance is Mr. Johnson experiencing? A. Metabolic acidosis. Although the pH is low, indicating acidosis, metabolic acidosis would be caused by a low HCO3. B. Metabolic alkalosis. Alkalosis is reflected by a high pH, rather than the low pH seen in these ABG results. C. Respiratory acidosis. Correct The low pH indicates that acidosis is present. The elevated pCO 2 indicates the problem is respiratory in nature. Clients with any condition that depresses respirations are prone to the development of respiratory acidosis. Even though Mr. Johnson has a rapid respiratory rate, his underlying COPD causes the retention of CO2. D. Respiratory alkalosis. Alkalosis is reflected by a high pH, rather than the low pH seen in these ABG results, although the high CO2 indicates there is clearly a respiratory problem! Page 3 1. 2. Nursing Diagnoses 4. Which nursing diagnosis has the highest priority when planning care for Mr. Johnson? A. Altered nutrition, less than body requirements. While it is true that clients with COPD typically exhibit nutritional problems, there is not sufficient data at this time to make this diagnosis. B. Activity intolerance. Clients with COPD often experience subtle progressive changes in their ability to complete ADLs. However, information related to this diagnosis has not yet been obtained from Mr. Johnson. C. Anxiety related to increased shortness of breath. While it is true that shortness of breath may increase Mr. Johnson's anxiety, it is not the priority diagnosis. D. Ineffective airway clearance. Correct There are adventitious breath sounds present, tachypnea, changes in depth of respirations, fever, and cough, all of which support this as a priority diagnosis. Additional priority diagnoses are impaired gas exchange and ineffective breathing patterns. Impaired gas exchange is reflected in Mr. Johnson's hypercapnia and hypoxia. The diagnosis of ineffective breathing pattern is supported by his tachypnea, use of accessory muscles, and changes in the depth of respiration. 3. When prioritizing needs, always remember the ABC's: Airway, Breathing, and Circulation. Nursing Interventions Mr. Johnson is admitted to his room on the Medical Nursing Unit. The healthcare provider prescribes the following: Bedrest with bedside commode. O2 at 2 L/minute via nasal cannula. Diet as tolerated. Continuous O2 saturation monitoring via pulse oximeter. IV fluid of 5% Dextrose and 0.45 Normal Saline at 3 liters per day. Obtain a sputum culture. Medications include: Ampicillin (Unasyn) 1 gm IVPB every 6 hours. Nebulizer treatments every 4 hours and PRN with saline and albuterol (Ventolin). Beclomethasone (Vanceril) inhaler, 2 puffs twice a day. Albuterol (Ventolin) inhaler, 2 puffs 4 times a day. Methylprednisolone (Solu-Medrol) 125 mg IVPB every 8 hours. 1. 2. 3. Medication Administration 5. Which nursing action should be implemented before administering the prescribed Unasyn? A. Assess the apical heart rate. This is not necessary prior to administering antibiotics. B. Obtain O2 saturation recording. This is not necessary prior to administering antibiotics. C. Obtain a sputum culture. Correct The sputum specimen should be obtained prior to initiating the first dose of antibiotics. Since Unasyn is a broad-spectrum bacteriocidal antibiotic, it is likely to be effective against the causative organism. Once the culture and sensitivity results are obtained, a different antibiotic may be used if necessary. Another important nursing intervention is to assess Mr. Johnson for previous allergic reactions to antibiotics. D. Record Mr. Johnson's weight. This is not necessary prior to administering antibiotics. 6. The Ampicillin (Unasyn) 1 gm IVPB is supplied in 50 mL of D5W to be delivered over 30 minutes. The nurse should set the IV pump at how many mL per hour? (Enter numerical value only. If rounding is necessary, round to the whole number.) Correct Correct Responses 1. 100 2 7. Which assessment is most important for the nurse to perform while Mr. Johnson is receiving Ventolin? 1. A. Monitor temperature. Monitoring Mr. Johnson's temperature is important because the findings are an indicator of a reduction in the infection, but that is not the most important assessment related to the albuterol. B. Measure intake and output. Measuring intake and output is important because it provides a valuable indicator of Mr. Johnson's fluid volume, but it is not the most important assessment related to the albuterol. C. Monitor pulse and BP. Correct Ventolin is a beta adrenergic agonist with a bronchodilating effect. Because adrenergic agonists mimic sympathetic stimulation, Mr. Johnson must be monitored carefully for cardiac arrhythmias, hypertension, nervousness, and restlessness. D. Measure central venous pressure (CVP). Measurement of CVP is used for clients at risk for severe fluid volume alterations. It is not needed for a client receiving albuterol. Client Teaching: Metered Dose Inhaler (MDI) The nurse observes Mr. Johnson as he uses his inhalers. Using a spacer, he takes 2 puffs of the Ventolin, followed a minute later by 2 puffs of the beclomethasone (Vanceril). 2. 8. After observing Mr. Johnson, what client teaching should the nurse initiate? A. "Administer the Vanceril first, followed by the Ventolin." The Ventolin (bronchodilator) should be used first, followed by the Vanceril (glucocorticoid). B. "Using a spacer reduces medication absorption." Actually, a spacer is an effective tool which helps to improve the amount of the medication that is absorbed when using MDIs. C. "Inhale deeply before sealing the mouthpiece." Mr. Johnson should exhale prior to sealing the mouthpiece with his lips. D. 3. "Wait at least 1 minute between each puff of the same medication." Correct Mr. Johnson should wait 1-2 minutes between each puff of the same medication. In addition, he should be instructed to wait 5 minutes before using the second medication. 9. Which instruction should the nurse provide Mr. Johnson for an acute episode of asthma? A. B. "Administer the Vanceril as soon as possible." Vanceril is a glucocorticoid with an antiinflammatory effect. It is used for long-term prevention in asthma, but it is not useful during acute episodes. "Use the Ventolin inhaler for acute asthma attacks." Correct Ventolin is a bronchodilator used for acute asthmatic attacks. 1. C. "Call your healthcare provider before administering any medication." Since Mr. Johnson has access to an effective method of self-care, that should be initiated first. D. "You will need IV Solu-Medrol for your next acute attack." Since Mr. Johnson has access to an effective method of self-care, that should be initiated first. Oxygen Saturation and Therapy Continuous monitoring of Mr. Johnson's oxygen saturation indicates readings ranging between 90%-91%. (Normal oxygen saturation values are 90%-100%). 2. 10. After checking the sensor site to make sure the readings are accurate, which intervention should the nurse initiate next? A. Increase the oxygen to 6 L/minute per nasal cannula. Since Mr. Johnson has chronic lung disease, it is not surprising that his saturation level is low. Clients with COPD should be maintained on low doses of oxygen since the drive to breathe is based on hypoxia, rather than hypercapnia. B. C. Elevate the head of the bed to a high-Fowler's position. Correct Semi to high-Fowler's positions decrease the pressure on the diaphragm and allow for improved lung expansion. Some clients with COPD prefer to lean forward and rest their upper body on an overbed table (tripod position). Remove the pulse oximeter to reduce anxiety. Continuous O2 saturation monitoring has been prescribed by the healthcare provider, and it should not be removed. This provides important ongoing monitoring of Mr. Johnson's oxygenation. D. 3. Obtain and administer a prescription for pain relief. There is no indication that Mr. Johnson is experiencing pain. 11. Which action should the nurse implement to ensure accurate oxygen saturation readings via a pulse oximeter? A. B. Elevate the extremity to which the sensor is attached. This is not necessary. Assess adequacy of circulation prior to applying the sensor. Correct The sensor will provide the most accurate reading if circulation is adequate. At regular intervals, the nurse should assess circulation and move the sensor to a new site. 1. C. Keep the sensor exposed to adequate lighting. A well-lit room is not necessary for the oximeter to function. To prevent inaccurate readings, at times the sensor may need to be protected from too much sunlight by placing the extremity under the bedcovers. D. Remove the sensor when taking the B/P. Blood pressure monitoring will disrupt pulsatile blood flow and affect the oximeter reading. However, a better intervention would be to take the B/P on the opposite extremity so as not to disrupt O2 monitoring. Displaced Anger The next morning, Mr. Johnson is scowling and complains that his breakfast is cold, his family has not yet been to visit him, and it was so noisy during the night that he was unable to sleep. Mr. Johnson seems angry, and the nurse recognizes that he may be using displacement of his anger as a defense mechanism. 2. 12. What is the best statement for the nurse to use to promote effective communication with Mr. Johnson? A. "I will make sure your door is closed tonight." This statement does not allow Mr. Johnson an opportunity to communicate his feelings. B. C. "You seem pretty upset this morning." Correct This statement allows an opportunity for Mr. Johnson to clarify his feelings. "Why are you feeling so angry?" Using "why" is considered a block to effective communication, and it should be avoided. D. "Remember, your son was here yesterday." This statement does not allow Mr. Johnson an opportunity to communicate his feelings. 3. In response to the nurse's effective communication, Mr. Johnson explains, "It seems like I've been sick so much. It's all the fault of those cigarette companies. I wouldn't be so sick if they had warned us about the dangers of smoking. I'll probably end up with cancer, and then I'll sue them." 4. 13. What is the nurse's best response? A. B. "You won't get cancer." This is false reassurance, which should be avoided. It blocks Mr. Johnson from further exploring feelings. "I know what you mean. I smoke, too." This self-disclosure has no therapeutic purpose and takes the focus away from Mr. Johnson. 1. C. "You should try not to worry about that now." This answer disregards Mr. Johnson's concerns and will block further communication. D. Remain silent. Correct This is the best choice. Silence can be a very effective communication technique. The nurse should express interest nonverbally when silence is used. Delegation and Supervision Later that morning, the unlicensed assistive personnel (UAP) helps Mr. Johnson transfer to the bedside commode. After he is back in bed, the nurse enters his room and observes that Mr. Johnson's oxygen saturation level is 85%, and he is not wearing his nasal cannula. He states that the cannula tubing wouldn't reach all the way to the commode, so the UAP removed it. 2. 14. What is the BEST nursing action? A. Institute a policy that UAPs may not provide care for clients with oxygen. Trained UAPs may provide care for clients with oxygen if given clear directions. UAPs can be delegated tasks that fall within the intervention component of the nursing process, but they must receive adequate supervision! B. Instruct the UAP involved regarding the inappropriate removal of the nasal cannula. Correct Helping Mr. Johnson to the commode is an appropriate action for a UAP to perform, but this UAP requires some additional instruction and individual supervision. C. Request the respiratory therapy to assist with Mr. Johnson's activities. This action is not necessary, since the UAP should be able to perform this responsibility with additional instruction and supervision. D. Assign an LVN to provide all care for Mr. Johnson in the future. This assignment is not necessary, since the UAP should be able to provide care for Mr. Johnson with additional instruction and supervision. 3. The National Council of State Boards of Nursing has defined five rights of delegation. 4. 15. Which one of these rights was violated in that situation? A. Right Task. This was an appropriate task to assign a UAP. Responsibilities should fall within the intervention component of the nursing process. B. Right Circumstance. Since Mr. Johnson was in stable condition, the circumstances for delegation were appropriate. C. Right Person. This is a task that could be delegated by an RN to a UAP. D. 5. Right Direction/Communication. Correct Since continuous oxygenation was a high priority for this client, the nurse's directions to the UAP should have emphasized the need for the nasal cannula to be left on at all times, especially during any activity. The fifth right, Right Supervision includes direction/guidance, evaluation/monitoring, and follow-up. Mr. Johnson's oxygen saturation level returned to 91% after the nurse reapplied the nasal cannula. The remainder of the day was uneventful, and Mr. Johnson's evening vital signs were T 99° F, P 84, R 22, BP 130/78. Lung sounds remained diminished, but the crackles were less audible, and Mr. Johnson was producing only minimal clear sputum. 6. A Complication Occurs During the night, Mr. Johnson calls the nurse to report a sudden inability to catch his breath. Upon assessment, the nurse notes that Mr. Johnson's respiratory rate has increased to 40 with obvious dyspnea, and his O2 saturation reading is 55. His pulse is 110, weak, and thready, and his blood pressure is 70/40. 7. 16. Which intervention should the nurse initiate immediately? A. Place resusitation equipment in the room. Correct This is a high priority, since Mr. Johnson's O2 saturation is dangerously low. The nurse should also prepare to transfer Mr. Johnson to the critical care unit for close monitoring. B. Administer a precordial thump. This is not initiated while a client has a pulse. The nurse should attach ECG leads to determine if a cardiac arrhythmia is occurring. C. Initiate CPR. Mr. Johnson still has a pulse, BP, and respirations, so CPR should not be initiated. D. Set defibrillator at 200 joules. This may be necessary if ventricular fibrillation develops, but it is not warranted at this time. 8. Mr. Johnson is transferred to the Medical Intensive Care Unit where he is treated for acute respiratory distress syndrome (ARDS). He is successfully treated with mechanical ventilator support, and he is in stable condition when he is transferred back to the Med-Surg Unit a week later. 1. Ethical-Legal Considerations As Mr. Johnson's condition improves, his son expresses concern that his father will continue to smoke. He asks the nurse if anti-smoking hypnosis tapes could be played during the night while his father is asleep. 2. 17. Which ethical principle is most important for the nurse to consider when responding to the son? A. B. Justice. This ethical concept refers to the assurance of fair treatment for all parties, which is always an important ethical consideration. However, there is a more relevant principle for this situation. Defamation. This legal concept refers to divulging confidential information, which is not an issue in this situation. C. Autonomy. Correct This ethical principle refers to the individual's right to make his own decisions regarding his care. It is an important principle, which would be violated if the nurse allowed the son to play hypnosis tapes without his father's knowledge or consent. D. 1. 2. Battery. This legal concept refers to touching another individual without their consent. This is not the issue in this situation. Discharge Teaching The remainder of Mr. Johnson's hospital stay is uneventful. 18. Which outcome statement is the best indicator that Mr. Johnson's pneumonia is resolved and he is ready to be discharged? A. Sputum culture is negative. Correct This is a significant indicator that the pneumonia is resolved. B. Unasyn peak and trough levels are within normal limits. This indicates that Mr. Johnson is receiving the correct dose of medication, but it does not indicate resolution of the infection. C. Oxygen saturation level is 92%. This low oxygen saturation level probably reflects Mr. Johnson's chronic pulmonary problems, rather than the pneumonia. D. Temperature is 98° F. This is one indicator of the resolution of an infectious process. However, it is important to make sure that Mr. Johnson's temperature is normal because of the resolution of the infection, not simply because he is receiving antipyretics. There is a better choice. 3. Mr. Johnson, his son, and the nurse discuss the use of anti-smoking hypnosis tapes, along with other measures to promote good health upon his discharge. Mr. Johnson agrees to follow all the discharge instructions and states that he understands the use of his medications, including the correct use of his metered dose inhaler. 4. 19. Which additional discharge instruction(s) should the nurse include in the teaching plan to promote optimal health for Mr. Johnson? (Select all that apply.) A. Avoid physical exertion. Regular exercise in moderation is an important factor in overall health. Mr. Johnson should be instructed in methods that will enable him to exercise safely, rather than instructed to avoid all exertion. B. Avoid crowds and people with infections. Correct This is an important measure to avoid future infections. Mr. Johnson should also be encouraged to get an annual pneumonia vaccine. C. Limit intake of oral fluids. Mr. Johnson needs to increase his oral fluid intake to maintain adequate hydration and keep respiratory secretions thin. D. Stay indoors except in the early morning. This is not necessary, although Mr. Johnson should be instructed to avoid being outdoors during high ozone alerts, or any other times when there are high levels of respiratory irritants in the air. E. Store prescribed inhalers away from extreme heat or colds. Correct Extreme heat and / or cold can alter the composition of the inhaler medication and render it ineffective. Case Outcome Mr. Johnson responds well to the discharge teaching and is successfully discharged to his home, accompanied by his son. Three months later, he visits the nurses on the medical unit and proudly tells them he has decreased his cigarette use to ½ pack per day.