A Diagnosis of COPD (Chronic Obstructive Pulmonary Disease) Exacerbation and Pneumonia (PNA)

Pneumonia

RF came to the Emergency Department (ED) at Northern Hospital of Surry County (NHSC) in Mount Airy, North Carolina on September 4, 2018, complaining of shortness of breath (SOB), tachypnea, and gasping for air. RF was soon admitted to the Step Down Intensive Care Unit (SDU) on September 4, 2018.

Diagnosis

RF was admitted to SDU with a diagnosis of COPD (Chronic Obstructive Pulmonary Disease) exacerbation and pneumonia (PNA). He was tested for Methicillin-resistant Staphylococcus aureus (MRSA) via a nasal swab, just prior to the student leaving the unit.

The results were not back by 1200 on Thursday, September 5, 2018.

Pathophysiology

Pneumonia is an infection that enters the body through inhalation. It causes inflammation in the lungs, often resulting in lung consolidation. Lung consolidation means pockets that are normally air-filled are filled with fluid. Most patients with pneumonia have increased thick mucus secretions (Lord, 2014).

Additional Diagnoses

RF's past medical history (PMH) includes COPD, hiatal hernia, Gastroesophageal Reflux Disease (GERD), and sleep apnea. RF complained of indigestion on Thursday, September 5, 2018, after breakfast. The student nurse reported his complaint to the charge nurse, who got an order for pantoprazole/Protonix.

Assessment

RF is a 61-year-old Caucasian male. His skin color is appropriate for his ethnicity. It is warm, dry, and intact without any signs of abuse. The client had not bathed in several days and did not feel like bathing himself. He was dirty, with dirt under his fingernails and on the soles of his feet. His skin turgor is elastic. RF remains in sinus tachycardia. His pulse consistently remained between 110 beats per minute (bpm) and 130 bpm, with a capillary refill of less than 3 seconds. Peripheral pulses are present, equal, and strong bilaterally. Tachypnea, labored breathing, inspiratory and expiratory wheezing with diminished breath sounds in the lower lobe were observed bilaterally on Wednesday. On Thursday, he showed some improvement; his breath sounds were wheezing on expiration only. Both days, he was very anxious and struggled to slow his respirations. He often needed coaching to breathe in through his nose.

Medications

RF is receiving lorazepam/Ativan 0.5 mg by mouth (PO) TID (three times a day) for anxiety. He becomes extremely anxious when his O2Sat decreases, and he begins to breathe through his mouth, which is ineffective because he is receiving oxygen (O2) via a high-flow nasal cannula (HFNC). The lorazepam did relax him, and during rest or while sleeping, his O2Sat remained at 100 percent. He is also taking Mucinex/guaifenesin 600 mg BID to thin his mucus, making it easier to cough up. Solu-Medrol/methylprednisone 125 mg/ml 80 mg q12h is given to suppress inflammation. RF also takes Tylenol/acetaminophen 325 mg prn for a pain scale of 1-3.

Diagnostic Exams

On September 4th, 2018, at 03:36, a Chest X-Ray (CXR) revealed potential multilobular Pneumonia (PNA). This was followed up with a chest CT at 04:16 that showed no Pulmonary Embolism (PE), PNA, bilateral pleural effusions, or severe emphysema.

Plan of Care

RF is receiving antibiotic treatment, bronchodilator nebulizer treatments, anti-anxiety medication, and oxygen. He is resting a lot due to extreme shortness of breath (SOB). The student nurse discussed physical activity and transferring the client out of bed (OOB) with the charge nurse. She felt it necessary to propose a physical therapy (PT) consultation with the hospitalist. However, RF has refused to get up and perform personal hygiene care.

Long and Short Term Goal

Short-term goals include bathing, oral hygiene, changing linen, keeping O2 SATs above 90%, coughing, turning and deep breathing, continuing the use of the nicotine patch, and not resuming smoking cigarettes upon release. Long-term goals: remain smoke-free and resume independent living. Just before lunchtime, the student nurse and a fellow classmate bathed RF, changed his bed linen and gown. Despite this, he refused oral hygiene. The student nurse responsible for RF reported his refusal to both the nursing assistant and the charge nurse.

Teaching

The student observed the registered nurse (RN) verbally educate RF about smoking cessation. He stated that he is aware of the dangers of smoking; however, he did not seem interested in continuing the conversation and will likely return to smoking upon discharge from the hospital.

Strengths and Weaknesses

The student nurse was knowledgeable about the client's condition, medications, and care needed. The student nurse was comfortable approaching other members of the disciplinary team to provide the best care possible for RF. She feels her weaknesses as a student nurse were convincing the client to perform activities of daily living (ADLs).

Personal Learning Goal

Learning goals met by student nurse, Amanda, included reporting tachypnea, tachycardia, and hypertension (HTN) to the charge nurse. Amanda was able to identify adventitious breath sounds, such as inspiratory wheezing, rhonchi, expiratory wheezing, and diminished breath sounds. She is continuing to sharpen her assessment skills, using time efficiently, and asking the assigned nurse, respiratory therapist, and nursing assistant pertinent questions related to this client and the unit.

The student nurse feels RF should be OOB to help loosen secretions and be encouraged to cough more. He should have an incentive spirometer (IS) at his bedside to aid in measuring his respiratory status. She also thinks he should be on medication(s) for HTN and tachycardia. During the student's end-of-shift report to the charge nurse, she agreed with the student in regards to his continued elevated blood pressure (BP) and heart rate (HR) and would follow up with the hospitalist assigned to care for RF.

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