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, 20018 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 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 mean pockets that are normally air filled being 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 did complain of indigestion Thursday, September 5, 2018 after breakfast. The student nurse reported his complaint to the charge nurse who got an order for pantaprazole/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 been bathed in several days and did not feel like bathing himself. He was unclean, dirt under fingernails and soles of the feet dirty. His skin turgor is elastic. RF remains in sinus tachycardia. His pulse consistently remained 110 beats per minute (bpm) to 130 bpm, capillary refill less than 3 seconds, peripheral pulses present, equal and strong bilaterally. Tachypnea, labored breathing, inspiratory and expiratory wheezing with diminished breath sounds in the lower lobe bilaterally on Wednesday. On Thursday he did show some improvement, his breath sounds were wheezing on expiration only. Both days he was very anxious and struggling to slow his respirations. He often had to be coached 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 is very anxious when his O2Sat’s decrease and begins to breathe through his mouth, which is ineffective because he is receiving oxygen (O2) via high flow nasal cannula (HFNC). The lorazepam did relax him and during rest and while sleeping his O2Sat remained at 100 percent. He is also taking Mucinex/guaifenesin 600 mg BID to thin his mucus to make it easier to cough up. Solu-Medrol/methylprednisone 125 mg/ml 80 mg q12h to suppress inflammation. Tylenol/acetaminophen 325 mg prn for a pain scale of 1-3.

Diagnostic Exams

On September 4th, 2018 at 0336 Chest X-ray (CXR) revealed multi lobular PNA likely. Followed up with a chest CT at 0416 that showed No PE (Pleural Embolism), PNA, bilateral pleural effusions and severe emphysema.

Plan of Care

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

Long and Short Term Goal

Short Term goals include bathing, oral hygiene, linen change, keeping O2SAT’s above 90%, coughing, turning and deep breathing, continue using the nicotine patch and do not resume smoking cigarettes when released. Long term goals to remain smoke free and begin living independently again. Just before lunch time the student nurse and a fellow classmate bathed RF and changed his bed linen and gown. He still refused oral hygiene, the student nurse assigned to care for RF reported his refusal to the NA and 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 (ADL’s).

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. 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 students 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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