COPD w/ Pneumonia case study
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.
Which assessment is most important for the nurse to complete next? a. Auscultate breath sounds. b. Auscultate heart sounds.. c. Assess for peripheral edema. d. Assess capillary refill.
Auscultate breath sounds. This is the highest priority because Mr. Johnson is clearly exhibiting respiratory distress
Discharge Teaching
The remainder of Mr. Johnson's hospital stay is uneventful.
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."
Which instruction should the nurse provide Mr. Johnson for an acute episode of asthma? a. "Administer the Vanceril as soon as possible." b. "Use the albuterol inhaler for acute asthma attacks." c. "Call your healthcare provider before administering any medication." d. "Take an extra dose of salmeterol for an acute attack."
"Use the albuterol inhaler for acute asthma attacks." Albuterol is a bronchodilator that is used for acute asthmatic attacks. Salmeterol is a long-acting bronchodilator that cannot be used more than 2 puffs every 12 hours and is not used for acute episodes.
After observing Mr. Johnson, which instruction by the nurse is most important for client teaching? (select all that apply) a. "Administer the beclomethasone first, followed by the salmeterol." b. "Using a spacer reduces medication absorption." c. "Wait at least 5 minutes between each medication." d. "Wait at least 1 minute between each puff of the same medication."
"Wait at least 5 minutes between each medication." - Mr. Johnson should wait at least 5 minutes before using the second medication. "Wait at least 1 minute between each puff of the same medication." - Mr. Johnson should wait 1 to 2 minutes between each puff of the same medication. In addition, he should be instructed to wait 5 minutes before using the second medication.
Which statement by the nurse promotes effective communication with Mr. Johnson? a. "I will inform the charge nurse of this and she will instruct the night staff to keep your door closed at night." b. "You seem pretty upset this morning." c. "Why are you feeling so angry?" d. "I can warm up your breakfast tray or order a fresh one for you."
"You seem pretty upset this morning." This statement allows an opportunity for Mr. Johnson to clarify his feelings.
The levofloxacin 500 mg IVPB is supplied in 100 mL of D5W to be delivered over 60 minutes. There is no IV pump available so the nurse will infuse the antibiotic by gravity. The drop factor on the tubing is 20 gtts/mL. The nurse should set the IVIVPB to infuse at how many gtts per min? (Enter numerical value only. If rounding is necessary, round to the whole number.)
33 gtts/min
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 diagnosis of COPD pneumonia and is transported to the nursing unit.
Arterial Blood Gas (ABG) Analysis Arterial Blood Gases were obtained with the following results: pH 7.25 pCO2 58 HCO3 26 pO2 87
While taking the client's blood pressure, the nurse observes the reading on the pulse oximeter to be fluctuating from 60 to 80. Which action should the nurse implement to ensure accurate oxygen saturation readings with the pulse oximeter? a. Place the extremity to which the sensor is attached at heart level. b. Assess the adequacy of circulation prior to applying the sensor. c. Lower the lighting in the room. d. Remove the sensor when taking the B/P.
Assess the adequacy of circulation prior to applying the sensor. 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.
After checking the sensor site to make sure the readings are accurate, the nurse should then initiate which intervention? a. Decrease the oxygen to 4 L/minute per nasal cannula. b. Elevate the head of the bed to a high-Fowler's position. c. Remove the pulse oximeter to reduce anxiety. d. Assess the client's respiratory rate and rhythm.
Assess the client's respiratory rate and rhythm. This is an acceptable oxygen saturation level for a client with COPD. The first action by the nurse is to assess the client's respiratory status and observe his effort of breathing.
Meet the Client: Darrell JohnsonDarrell Johnson is a 62-year-old male who comes to the Emergency Department (ED) with a 4-day 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 (Ventolin) inhalers from time to time as an adult. Mr. Johnson has been hospitalized twice with pneumonia; the most recent pneumonia-related hospitalization was 2 years ago.
Assessment The physical examination reveals the following: Vital signs: T 101.6° F, P 110, R 32, BP 132/78. Respirations shallow and labored, with use of respiratory accessory muscles. Increased anteroposterior (AP) diameter of the chest. Skin dry and warm to touch, with inelastic skin turgor, and fingernail clubbing present.
Which ethical principle is most important for the nurse to consider when responding to the son? a. Veracity. b. Beneficence. c. Autonomy. d. Nonmaleficence.
Autonomy. 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.
Which additional discharge instructions should the nurse include in the teaching plan to promote optimal health for Mr. Johnson? Select all that apply a. Decrease physical activity. b. Avoid crowds and people with infections. c. Increase intake of oral fluids. d. It is all right to go outside anytime. e. Store prescribed inhalers away from extreme heat and cold.
Avoid crowds and people with infections. (This is an important measure to avoid future infections.) Mr. Johnson should also be encouraged to get an annual pneumonia vaccine.) Increase intake of oral fluids. (Mr. Johnson needs to increase his oral fluid intake to maintain adequate hydration and keep respiratory secretions thin.) Store prescribed inhalers away from extreme heat and cold. (Extreme heat and cold can alter the composition of the inhaler medication and render it ineffective.)
Medication Administration Mr. Johnson is admitted to his room on the Medical Nursing Unit and the healthcare provider prescribes the following:
Bedrest with bedside commode O2 at 2 L/minute via nasal cannulaDiet 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: Levofloxacin 500 mg IVPB every 24 hours Nebulizer treatments every 4 hours and PRN with saline and albuterol Beclomethasone inhaler, 2 puffs twice a day. Salmeterol inhaler, 2 puffs every 12 hours Methylprednisolone (Solu-Medrol) 125 mg IVPB every 8 hours.
Oxygen Saturation and Therapy
Continuous monitoring of Mr. Johnson's oxygen saturation indicates readings ranging between 92%-93%. (Normal oxygen saturation values are 90% to 100%).
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 Medical-Surgical Unit a week later.
Which nursing diagnosis has the highest priority when the nurse is planning care for Mr. Johnson? a. Imbalanced nutrition, less than body requirements. b. Impaired physical mobility. c. Deficient fluid volume. d. Ineffective airway clearance.
Ineffective airway clearance. There are adventitious breath sounds present, tachypnea, changes in depth of respirations, fever, and cough, 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.
What is the best nursing action? a. Report the UAP to the charge nurse for performing an act that was not allowed. b. Instruct the UAP involved regarding the inappropriate removal of the nasal cannula. c. Request that a second UAP assist the UAP the respiratory therapist to assist with Mr. Johnson's activities. d. Assign the UAP to a different client.
Instruct the UAP involved regarding the inappropriate removal of the nasal cannula. 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 with oxygen equipment.
Delegation and Supervision
Later that morning, the unlicensed assistive personnel (UAP) helps Mr. Johnson transfer to the bedside commode. After Mr. Johnson is back in bed, the nurse enters his room and observes that Mr. Johnson's oxygen saturation level is 85% and that 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.
While Mr. Johnson is undergoing nebulizer treatments with albuterol, it is most important for the nurse to perform which assessment? a. Monitor pulse oximeter readings. b. Monitor respiratory rate. c. Monitor pulse and BP. d. Monitor temperature.
Monitor pulse and BP. Albuterol (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.
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 of the discharge instructions and states that he understands the use of his medications, including the correct use of his metered dose inhaler.
A Complication Occurs
Mr. Johnson's oxygen saturation level returns to 91% after the nurse reapplies the nasal cannula. The remainder of the day is uneventful, and Mr. Johnson's evening vital signs are T 99° F, P 84, R 22, BP 130/78. Lung sounds remain diminished, but the crackles are less audible, and Mr. Johnson is producing only minimal clear sputum. 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
Which nursing action should be implemented before the prescribed levofloxacin is administered? a. Auscultate lung sounds. b. Assess oral intake. c. Obtain a sputum culture. d. Assist client to the bathroom.
Obtain a sputum culture. The sputum specimen should be obtained prior to initiation of the first dose of antibiotics. Since levofloxacin is a broad-spectrum bactericidal 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 assessment of Mr. Johnson for previous allergic reactions to antibiotics.
Which intervention should the nurse initiate immediately? a. Place resuscitation equipment in the room. b. Increase the O2 to 6 L/min. c. Initiate CPR. d. Set defibrillator at 200 joules.
Place resuscitation equipment in the room. This is a high priority because 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.
Which assessment finding supports Mr. Johnson's diagnosis of pneumonia? a. Pulse rate of 110. b. BP of 132/78. c. Increased AP diameter of the chest. d. Inelastic skin turgor.
Pulse rate of 110. 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.
What is the nurse's best response? a. "You may be one of the lucky ones and not get cancer." b. "I understand that. I have been trying to quit smoking for a few years but have not been successful." c. "You should focus on getting better and try not to worry about that now." d. Remain silent.
Remain silent. This is the best choice. Silence can be a very effective communication technique. The nurse should express interest nonverbally when silence is used.
These ABG results indicate that Mr. Johnson is experiencing which acid base imbalance? a. Metabolic acidosis. b. Metabolic alkalosis. c. Respiratory acidosis. d. Respiratory alkalosis.
Respiratory acidosis. pH 7.25 - low pCO2 58 - high HCO3 26 - normal The low pH indicates that acidosis is present. The elevated pCO2 indicates that 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.
The National Council of State Boards of Nursing has defined five rights of delegation. Which one of these rights was violated in this situation? a. Right Task. b. Right Circumstance. c. Right Person. d. Right Direction/Communication.
Right Direction/Communication. 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 the client at all times, especially during any activity. The fifth right, Right Supervision includes direction/guidance, evaluation/monitoring, and follow-up.
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. b. Levofloxacin peak and trough levels are within normal limits. c. Oxygen saturation level is 92%. d. Clear sputum.
Sputum culture is negative. This is a significant indicator that the pneumonia is resolved.
Therapeutic Communication
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.
Client Teaching: Metered Dose Inhaler (MDI)
The nurse observes Mr. Johnson as he uses his inhalers. Using a spacer, Mr. Johnson takes 2 puffs of the salmeterol, followed a minute later by 2 puffs of the beclomethasone.
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 he proudly tells them that he has decreased his cigarette use to 1/2 pack per day.
