NGN: Case study on PNEUMONIA 1
Health History
1000:Health history: Diabetes mellitus type 2, hypertension, resolved atrial fibrillation treated with amiodarone, which was discontinued 1 month ago Medications:Apixaban 5 mg orally twice dailySemaglutide 1 mg subcutaneously weeklyCarvedilol 3.125 mg orally twice dailyLisinopril 5 mg orally dailyT 101.0°F (38.3°C), HR 110 BPM regular, RR 24 bpm rapid and shallow, BP 138/72 mmHg, SpO2 level 90% on RA, states burning pain in throat when breathingDenies recent travel or exposure to anyone who is sick. Reports exposure to smoke in the air from the nearby forest firesDenies headache or muscle aches Shortness of breath when talking, crackling heard in right lower lobe on auscultation of lungs
Nurses Notes
10:30: The nurse reports the assessment findings to the nurse practitioner (NP) and diagnostic and laboratory tests were prescribed. 11:00: The test results are reported as follows.
UPDATED NOTES
1130: The client is diagnosed with pneumonia, and levofloxacin 500 mg orally daily is prescribed. Other prescriptions include 1200 mg guaifenesin oral extended-release tablets every 12 hours, and an albuterol sulfate inhaler for every 6 hours as needed for shortness of breath/wheezing. Prior to discharge, the client received an albuterol/ipratropium respiratory treatment. Following the treatment, the client's SpO2 reading was 95% RA. A follow up visit at the clinic is scheduled in 10 days. 1000, 72 hours later:The client returns to the clinic and reports is experiencing more symptoms. The client has been taking the medications as prescribed but has been experiencing heart palpitations, diarrhea, and muscle pain and weakness. The client reports that most of the pain is in the legs and around the knees and ankles, and feels like the "legs won't hold up when standing." The client is questioning if contracting the flu is a possibility now.The nurse reviews the notes from the initial clinic visit and performs an assessment and ECG and documents the following in the nurses' notes.
Admitting Info
A 69-year-old client visits the clinic because the client has been experiencing a sore throat, earache, and cough. The client reports the cough has worsened and now is very congested and coughing up yellow mucus. The client also reports a low-grade temperature, chills, and sweats. The client reports diminished appetite but was able to tolerate toast, peanut butter, and orange juice before coming to the clinic. The client reports receiving the second COVID-19 vaccine 3 days ago.
UPDATED PHYSICIAN ORDERS
Discontinue levofloxacin and instruct client to inform other health care providers that the medication should not be taken. Potassium oral supplements: 20 mEq orally daily Continue 1200 mg guaifenesin oral extended-release tablets every 12 hours, and albuterol sulfate inhaler every 6 hours as needed for shortness of breath/wheezing. Resume other prescribed medications: Apixaban 5 mg orally twice daily Semaglutide 1 mg subcutaneously weekly Carvedilol 3.125 mg orally twice daily Lisinopril 5 mg orally daily See cardiologist for consult; appointment scheduled for tomorrow. Return to the clinic in 1 week for follow-up. 1200:The nurse reviews the discharge orders and provides discharge instructions to the client.
For each client finding, click to specify if the finding is most consistent with the current infectious process, an influenza infection, or an adverse medication effect. Each finding may support more than one condition. Client Findings: a. T 99.0°F (37.2°C) b.Muscle aches and weakness in both legs c.Pain level in knees, ankles, heels d.Expectorating yellow mucus e. Diarrhea f.ECG result g.Heart palpitations
RATIONALE: Levofloxacin is a fluoroquinolone and is a potent bactericidal broad-spectrum antibiotic. Fluoroquinolones are active against a wide variety of gram negative and selected gram-positive bacteria. These antibiotics can cause a variety of adverse effects. Central nervous system effects include headache, dizziness, insomnia, restlessness, neuropathy, seizures, and depression. Gastrointestinal effects include nausea, vomiting, diarrhea or constipation, heartburn, dysphagia, oral candidiasis, and increased liver enzyme levels. Integumentary effects include rash, pruritis, urticaria, and flushing. The most concerning adverse effect involves prolongation of the QT interval on the ECG and dangerous cardiac dysrhythmias. These ECG changes are more likely to occur when fluoroquinolones are taken by clients who are also receiving class Ia and class III antidysrhythmics, such as amiodarone. The US Food and Drug Administration requires a black box warning for all fluoroquinolones because of the increased risk for tendonitis and tendon rupture with these medications. The client's temperature and the expectoration of yellow mucus is most consistent with the current infectious process. Although the temperature and muscle aches and weakness in the legs are a manifestation associated with an influenza infection, there are no other indications that this client has influenza. Additionally, the influenza test done 72 hours ago was negative. The muscle aches and weakness in the legs along with the characteristics of the pain that the client is experiencing and the pain levels is characteristic of tendonitis, an adverse effect of the medication. Diarrhea is also most consistent with an adverse effect of the medication. The ECG result and the client report of heart palpitations is consistent with an adverse effect of fluoroquinolones. CJ Cognitive Skills: Analyze Cues Content Area: Pharmacology Priority Concept: Gas Exchange
Check (click) to specify if the client statement indicates an understanding of the instruction or indicates the need for additional teaching. Client Statement a."I should take the potassium if my muscles feel weak." b."If the cardiologist says I am fine, I won't need to come back to the clinic in a week." c."When I collect my stool sample, I need to get it to the laboratory as soon as possible and within 24 hours." d."I need to take the potassium pill with some food and a full glass of water so it doesn't upset my stomach." e. "I can probably just hang on to the antibiotics that I have left in case someone in my family comes down with this same infection and needs them."
RATIONALE: Medication needs to be taken as prescribed. The NP ordered potassium oral supplements 20 mEq orally daily. Therefore, if the client states, "I should take the potassium if my muscles feel weak," there is a need for additional teaching because the supplement needs to be taken daily. If the client does not adhere to the prescribed daily schedule, then erratic potassium levels are a concern and could lead to cardiac problems. The client does understand the instruction if the client states to take the potassium pill with some food and a full glass of water. Potassium can be harsh and irritating on the stomach lining so taking it with food and a full glass of water helps eliminate any irritation and discomfort. There is a need for additional teaching if the client states, "If the cardiologist says I am fine, I won't need to come back to the clinic in a week." The nurse needs to stress the importance of returning to the clinic for follow-up not only to review the cardiologist findings and recommendations but also for follow-up on the respiratory illness to assess for improvement and resolution of the problem. Collected stool specimens do need to be transported to the laboratory for testing as soon as possible and within 24 hours of collection, so this statement by the client indicates an understanding. The client should never share medication with others, so if the client states it is acceptable to do so, then additional teaching is necessary. CJ Cognitive Skills: Evaluate Outcomes Content Area: Pharmacology Priority Concept: Gas Exchange
Which of the following findings require immediate follow-up? Select all that apply. BP reading WBC count SpO2 level Temperature Chest x-ray results Blood glucose result Smoke exposure event Second COVID vaccine received 3 days ago
RATIONALE: The WBC count and the temperature are elevated. This is indicative of an acute infectious process and warrants immediate attention. The chest x-ray shows opacity in the right lower lobe, the area that the nurse heard crackles, and this finding further supports the presence of an acute infectious process. The SpO2 level is low, supporting altered airway clearance and the presence of an infectious process in this client. The client's symptoms of sore throat, earache, cough and congestion, chills and sweats, and shortness of breath also correlate with infection. Although the systolic BP is elevated above normal, it is not a significant finding and is expected considering the client's respiratory status. The blood glucose is elevated but the client reports eating toast and peanut butter and drinking orange juice, so a post-prandial glucose level of 135 mg/dL (7.52 mmol/L) is expected. The smoke exposure event is likely a contributing factor to the respiratory problem but at this time does not require immediate attention. Having received a second COVID-19 vaccine 3 days ago is insignificant; additionally, the COVID-19 antigen test was negative. CJ Cognitive Skills: Recognize Cues Content Area: Pharmacology Priority Concept: Gas Exchange
Which orders would the nurse anticipate for the client at this time? Select all that apply. a. Stool culture b.Cardiology consult c.Repeat COVID-19 test d.Repeat influenza test e.Blood draw for electrolyte levels f.Decrease the dose of the levofloxacin to 250 mg daily
RATIONALE: The client is experiencing adverse effects of the levofloxacin as evidenced by the prolonged QT interval on the ECG and the client symptoms of palpitations and light headedness. Additionally, the client is experiencing muscle aches and weakness in both legs and pain of 5/10 on 0 to 10 pain scale circumferentially in knee area bilaterally and 7/10 on 0 to 10 pain scale on the lateral side of ankles and heels bilaterally, indicative of tendonitis and the risk of tendon rupture. Since the client is experiencing adverse effects of the antibiotic, the order would be to discontinue the medication rather than decrease the dose. A cardiology consult would be warranted to evaluate the prolongation of the QT interval. Although this is an adverse effect of the antibiotic, the client has a history of atrial fibrillation and was taking amiodarone up until one month ago. Dangerous cardiac dysrhythmias are more likely to occur when fluoroquinolones are taken by clients who are also receiving class Ia and class III antidysrhythmics, such as amiodarone. Amiodarone has a very long half-life and as a result, the therapeutic as well as any adverse effects may last long after the medication has been discontinued. It may take as long as two to three months for the medication to be eliminated from the body. A stool for culture may be important to obtain since the client is having diarrhea and because of the risk of antibiotic associated (or Clostridium difficile-associated) colitis. Electrolyte levels, especially the potassium level, would be important to assess. Because of the client's cardiovascular symptoms and the ECG findings, along with the fact that the client has a poor appetite and is experiencing muscle weakness, the electrolyte levels could be abnormal; if they are, replacement would be necessary to prevent further cardiovascular effects. There is no need to repeat the COVID-19 or influenza tests. Except for the muscle aches and weakness and low-grade temperature, there are no other manifestations indicative of influenza. CJ Cognitive Skills: Generate Solutions Content Area: Pharmacology Priority Concept: Gas Exchange
UPDATED NURSES NOTES
T 99.0°F (37.2°C), HR 88 BPM regular, RR 18 bpm, BP 140/80 mmHg, SpO2 95% RA Pain: 5/10 on 0 to 10 pain scale circumferentially in bilateral knees; 7/10 on 0 to 10 pain scale lateral side of ankles and heels bilaterally. Reports muscle ache and weakness in both legs.States sore throat, earache, the burning pain in throat is resolved.Cough and congestion are unchanged; expectorating white mucus.Appetite is still poor, reports diarrhea and lightheadedness.No shortness of breath when talking, crackling heard in right lower lobe on auscultation of lungs. ECG: Prolongation of the QT intervalSputum culture: Negative
Complete the following sentence from the lists of options provided. The immediate action the nurse would take is ANSWER 1 followed by ANSWER 2. ANSWER OPTION 1 and ANSWER OPTION 2 a. discontinue the levoflocacin b. draw blood to check the electrolyte levels c. contact cardiology to schedule an appointment for a consult d. teach the client about the procedure for obtaining a stool specimen
The immediate action the nurse would take is discontinue the levofloxacin followed by drawing blood to check the electrolyte levels . RATIONALE The client is experiencing adverse effects of the levofloxacin as evidenced by the prolonged QT interval on the ECG and the client symptoms of palpitations and light headedness. This is a concern because of the risk for life-threatening dysrhythmias. The client is also experiencing muscle aches and weakness in both legs and pain circumferentially in both knees, ankles, and heels, indicative of tendonitis and the risk of tendon rupture. Since the client is experiencing adverse effects of the antibiotic, the medication needs to be discontinued immediately as a first action. Next, the nurse would draw blood to send to the laboratory to check the electrolyte levels. The client's electrolyte levels could be abnormal since the client is experiencing cardiovascular symptoms and has a poor appetite and muscle weakness. Replacement therapy would be necessary if any electrolyte levels are abnormal to prevent further cardiovascular effects. It may take time for the laboratory to run the test and get the results reported to the nurse, so this should be the nurse's next action. While awaiting the results of the electrolyte values, the nurse would contact the cardiologist office to schedule the appointment for the consult and would then teach the client the procedure for collecting a stool specimen and the transport procedure for getting the specimen to the laboratory. CJ Cognitive Skills: Take Action Content Area: Pharmacology Priority Concept: Gas Exchange
Complete the following sentence from the lists of options provided. The nurse reviews the assessment findings and determines that the priority client need is to address ANSWER 1 the followed by ANSWER 2. ANSWER 1 OPTIONS Diarrhea ECG result Temperature Muscle Aches, weakness, and pain ANSWER 2 OPTIONS Diarrhea ECG result Temperature Muscle Aches, weakness, and pain
The nurse reviews the assessment findings and determines that the priority client need is to address the ECG result followed by muscle aches, weakness, and pain . RATIONALE: The most concerning adverse effect for all fluoroquinolones involves prolongation of the QT interval on the ECG. Airway, breathing, and circulation (ABCs) are always the priority, and additionally, the client is reporting heart palpitations and lightheadedness, so this finding needs to be addressed first to prevent the development of a life-threatening dysrhythmia. The US Food and Drug Administration requires a black box warning for all fluoroquinolones because of the increased risk for tendonitis and tendon rupture with these medications. The client is reporting muscle aches and weakness in both legs and pain 5/10 on 0 to 10 pain scale circumferentially in knee area bilaterally and 7/10 on 0 to 10 pain scale on the lateral side of ankles and heels bilaterally. These findings are characteristic of tendonitis and need to be addressed. Diarrhea may be an adverse effect of the fluoroquinolone and should be further assessed because of the risk of antibiotic associated (or Clostridium difficile-associated) colitis, but is not the priority given the options provided. The client's temperature, although elevated, is not a concern because this is expected, even if the infection is due to a virus. Additionally, the temperature is lower than the temperature at the initial clinic visit, indicating an improvement. CJ Cognitive Skills: Prioritize Hypotheses Content Area: Pharmacology Priority Concept: Gas Exchange
UPDATED NURSES NOTE
The nurse reviews the notes from the initial clinic visit and performs an assessment and ECG and documents the following in the nurses' notes. T 99.0°F (37.2°C), HR 88 BPM regular, RR 18 bpm, BP 140/80 mmHg, SpO2 95% RA Pain: 5/10 on 0 to 10 pain scale circumferentially in bilateral knees; 7/10 on 0 to 10 pain scale lateral side of ankles and heels bilaterally. Reports muscle ache and weakness in both legs.States sore throat, earache, the burning pain in throat is resolved.Cough and congestion are unchanged; expectorating white mucus.Appetite is still poor, reports diarrhea and lightheadedness.No shortness of breath when talking, crackling heard in right lower lobe on auscultation of lungs. ECG: Prolongation of the QT intervalSputum culture: Negative
