RELEVANT are vitals so be concerned with.

RELEVANT Data from
Present Problem:

Clinical Significance:

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1. Persistent
productive cough with green phlegm
2. Prednisone 40mg and
Azithromycin 250 mg three days ago
3. Chills and Fever
4. Difficulty breathing at night
and using albuterol inhaler w/o improvement

1. This is a sign of infection
and the body trying to fight it off.
2. Prednisone is used for
inflammation and azithromycin is used to fight against susceptible bacteria.
3. Chills and fever are also
signs of infection.
4. Difficulty breathing w/o
improvement from inhaler means that O2 is decreasing in the lungs and she is
in distress.
All of these point me toward a
respiratory infection

RELEVANT Data from
Social History:

Clinical Significance:

1. Widowed 6 months ago
2. Assisted living
3. Called pastor
4. Beginning of end

1. She is still going
through loss of husband and many emotions come from that.
2. Assisted living and being 84
means she is more susceptible to infections
3. Religious person and may need
pastor to help with coping
4. Thinking that this may be the
beginning of the end shows a poor outlook on her life and may need to be
addressed later after primary problem is under control.



Clinical Significance:

Respiratory Rate
Blood pressure
O2 saturation

Temperature of 103.2
degrees F, Pulse rate of 110, Respiratory rate of 30, blood pressure of
178/96, 86% oxygen saturation are vitals so be concerned with. First the
oxygen saturation of 86% means that not enough oxygen is getting to the lungs
and part of the respiratory system is compromised. This could be due to her
COPD or if she has asthma. High temperature is still showing that there is an
infection that the body is trying to fight off. Blood pressure of 178/96
shows signs of hypertension or due to pain. Pulse of 110 could be because of
the pain she is experiencing and is regular, so it is classified as sinus
tachycardia. (Lewis et al., 2017, p. 763) Her pain is achy on deep breathing
and shallow breathing, and generalized over the right side and intermittent is
probably caused by inflammation and coughing for four days or COPD


RELEVANT Assessment

Clinical Significance:

Anxious and distress
Barrel chest
Dyspnea with accessory muscles
Diminished breath sounds
Expiratory wheezing
Pale, hot & dry
Alert and Oriented x4

Patients who are anxious and in
distress can increase blood pressure and pulse. Barrel chest is a sign of
COPD. Dyspnea with accessory muscles tells us that she is having a hard time
breathing and is seen in COPD (ATI, 2016, p. 129). Diminished breath sounds,
and expiratory wheezing could be a sign of asthma exacerbation (Lewis et al.,
2017, p. 466). Hot to the touch tells us her temperature is elevated which
was stated before showing signs of infection. Patient is alert and orientated
x4 which is showing that she has not had neuro complications yet with present
problem. Decreased oxygen can cause altered mental status.


12 Lead EKG


 Sinus Tachycardia

Clinical Significance:

“Sinus tachycardia is associated
with physiologic and psychologic stressors such as exercise, fever, pain,
hypotension, hypovolemia, anemia, hypoxia, hypoglycemia, myocardial ischemia,
heart failure (HF), hyperthyroidism, anxiety, and fear” (Lewis et al., 2017,
p. 763). HR for ST is above 100 bpm with normal p wave, along with QRST.



Clinical Significance:

Left lower lobe infiltrate.
Hypoventilation present in both lung fields

Fluid build up in lower left lobe
which is a sign of pneumonia and hypoventilation happens in exacerbation of
COPD (ATI, 2016, p. 112).


Complete Blood Count (CBC)




WBC (4.5–11.0 mm 3)




Hgb (12–16 g/dL)




Platelets(150–450x 103/µl)




Neutrophil % (42–72)




Band forms (3–5%)






Clinical Significance:

TREND: Improve/Worsening/Stable:     

Band Forms

Neutrophils take in the bacteria
first as they are the first to respond to an injury. They have a short life
so more must be produced rapidly and with that WBC increase also. Band forms
are immature neutrophils and are found more in acute bacterial infections. (Lewis et al., 2017, p. 160)

WBC – Increasing
Neutrophils – Increasing
Band forms – Improving


Basic Metabolic Panel (BMP:)




Sodium (135–145 mEq/L)




Potassium (3.5–5.0 mEq/L)




CO2 (Bicarb) (21–31 mmol/L)




Glucose (70–110 mg/dL)




BUN (7–25 mg/dl)




Creatinine (0.6–1.2 mg/dL)




Misc. Labs:



Most Recent:

Lactate (0.5–2.2 mmol/L)



















Clinical Significance:


Sodium, potassium, CO2, Glucose,
BUN, and lactate.

Sodium and potassium being within
normal limits meaning the body is trying to stay in homeostasis. Sodium
determines extracellular fluid osmolality and potassium determines
intracellular fluid osmolality. (Lewis et al., 2017, p. 278-280) CO2,
Glucose, BUN and lactate being high means acidosis. CO2 is bicarbonate and is
affected by lung function. Glucose is high possibly from taking prednisone.
(Prednisone, n.d.) BUN is normally higher in older adults due to changes in
the body. (Lewis et al., 2017) It can also be elevated due to the
azithromycin she was prescribed. (Azithromycin, n.d.) Lactate “usually
increases once significant hypoperfusion and impaired O2 utilization at the
cellular level have occurred. By-product of anaerobic metabolism” (Lewis et
al., 2017, p. 1589).

Sodium: stable
Potassium: stable
CO2: worsening
Glucose: worsening
BUN: worsening
Lactate: Increased (not prior





Arterial Blood Gas:



pH (7.35–7.45)



pCO2 (35–45)



pO2 (80–100)



HCO3 (18–26)



O2 sat (>92%)





Clinical Significance:

pH, pCO2, pO2, HCO3, O2

Low pH means the blood is acidic
and could be caused by Ventilatory failure, pulmonary diseases, pulmonary
edema, renal failure, lactic acidosis and ketoacidosis. pCO2 being high means
too much CO2 is in the body and that is caused by pulmonary edema and obstructive
lung disease. pO2 being low tells us that there is not enough oxygen in the
blood and can be caused by COPD, restrictive pulmonary disease and
hypoventilation. HCO3 is bicarbonate and is mostly controlled from the
kidneys. HCO3 neutralizes acid in the blood. O2 saturation being low also
meaning not enough oxygen is getting into the body this could be due to an
airway obstruction such as during an asthma attack or lung diseases like
COPD. (“ABG (arterial blood gases)”, n.d.) These are all characteristics of
respiratory acidosis. (Lewis et al., 2017, p. 288)







Urine Analysis (UA):



Color (yellow)



Clarity (clear)



Specific Gravity (1.015–1.030)



Protein (neg)



Glucose (neg)



Ketones (neg)



Bilirubin (neg)



Blood (neg)



Nitrite (neg)



LET (Leukocyte Esterase) (neg)






RBCs (<5) 1 WNL WBCs (<5) 3 WNL Bacteria (neg) Few WNL Epithelial (neg) Few  WNL   RELEVANT Lab(s):  Clinical Significance: TREND: Improve/Worsening/Stable:      All UA labs are relevant as there are no abnormalities. Bacteria and Epithelial micro labs   Normal UA labs means that the kidneys are still working correctly are excreting properly. Bacteria and epithelial cells in the urine are normal in small amounts. If they start increasing that would be cause for concern. (Klatt, 1994-2017)  Stable   1.         What is the primary problem that your patient is most likely presenting with? Respiratory infection (pneumonia) along with COPD exacerbation 2.         What is the underlying cause/pathophysiology of this primary problem? COPD, living in assisted living where spread of infection increases. Care Provider Orders: Rationale: Expected Outcome: 1. Albuterol-ipratropium 2.5 mg neb 2. Establish peripheral IV 3. Lorazepam 1 mg IV push every 6 hours prn anxiety  4. Methylprednisolone 125 mg IV push 5. Levofloxacin 750 mg IVPB (after blood cultures drawn) 6. Acetaminophen 1000mg oral 1. Bronchodilators used for exacerbations of asthma and COPD. Albuterol is a adrenergic that binds to beta-2 receptors and ipratropium is an anticholinergic that hinders cholinergic receptors. (Albuterol, n.d.) (Ipratropium, n.d.) 2. Peripheral IV is needed for venous access to give medications. 3. Benzodiazepine used for antianxiety. (Lorazepam, n.d.) This will calm the patient down and maybe help her focus on breathing. This needs to be used cautiously with her because of the COPD. 4. Corticosteroid used to subdue inflammation. It is used IV so the effects are faster as it can also be given IM. It will help open the airway and help with O2 and CO2 exchange. (Methylprednisolone, n.d.) 5. Fluoroquinolone used for anti-infectives. This medication "inhibits bacterial DNA synthesis by inhibiting DNA gyrase enzyme" (Levofloxacin, n.d.). In simple terms it kills bacteria. 6. Nonopioid analgesic and antipyretic that is being used for reducing fever and for mild pain. It does not reduce any inflammation. (Acetaminophen, n.d.) 1.  Bronchodilation 2. Patent venous line 3. Calm patient 4. Decrease inflammation of the bronchial 5. Fight infection, keep out of sepsis/shock 6. Reduce fever   Care Provider Orders: Order of Priority: Rationale: 1. Albuterol-ipratropium 2.5 mg neb 2. Establish peripheral IV 3. Lorazepam 1 mg IV push 4. Methylprednisolone 125 mg IV push 5. Levofloxacin 750 mg IVPB (after blood cultures drawn) 6. Acetaminophen 1000mg PO 1. Albuterol-ipratropium 2. Peripheral IV 3. Lorazepam 4. Methylprednisolone 5. Levofloxacin 6. Acetaminophen  In a situation like this you are concerned with ABC's (airway, breathing, circulation) first. 1. Bronchodilation to help with air flow and airway management. 2. IV access to give medications 3. Calm patient (decrease anxiety) maybe able to focus on breathing more. 4. Decreases bronchoconstriction 5. Kill bacteria that is causing infection in the body 6. Reduce fever.   3.         What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY) Ineffective airway clearance Impaired gas exchange Risk for infection Acute pain (chest) Nursing Interventions: Rationale: Expected Outcome: 1. Ineffective airway clearance - Assess respirations: rate and depth and chest movement.         - Auscultate lungs and note abnormalities - Teach deep-breathing exercises, splinting of chest and effective coughing while in upright position.        - Start IV fluids > normal mL
needed/day unless contraindicated.
– Give nebulizer and other
medications as prescribed by doctor              
– Monitor labs and other tests for
improvement or decline including x-rays, ABG’s and BMP.
(Vera, 2013)
2. Impaired gas exchange    
– Assess mental status.           
– Monitor heart rate and rhythm.       
– Monitor body temperature.
– Elevate head and encourage
frequent position changes, deep breathing, and effective coughing.    
– Assess anxiety level 
– Observe for deterioration    
– Administer oxygen therapy
(Vera, 2013)
3. Risk of infection
– Monitor vital signs closely
during therapy
– Teach patient about secretions
and how they look. They need to report any changes.
– Limit visitors if indicated to
make sure infection doesn’t spread.
– Rest and activity need to be
– Tell patient to report deterioration
of symptoms.
(Vera, 2013)
4. Acute Pain
– Assess
pain and characteristics. Report changes in feeling
– Provide comfort: position
changes, and medications.
– Oral hygiene needs to be
(Vera, 2013)

– Assessment of the respiratory
system can help determine a basis of what is going on.
– Auscultation of lungs can be
clear which is normal. Crackles, rhonchi, and wheezes and can be heard as
abnormalities and can be due to fluid, thick secretions, spasms and
– Deep breathing, splinting, and
effective coughing provide expansion, patent airways, and reducing discomfort.

– “Nebulizers and other
respiratory therapy facilitates liquefaction and expectoration of secretions.
Postural drainage may not be as effective in interstitial pneumonias or those
causing alveolar exudate or destruction. Coordination of treatments and oral
intake reduces likelihood of vomiting with coughing, expectorations” (Vera,
2013, p. 1).
– Laboratory results and other
tests being monitored can help with seeing if the patient is progressive
further into diseases or improving to normal state.
(Vera, 2013)
– Any change in mental status
could be caused by impaired gas exchange from the lungs or any point in the respiratory
– Fever can cause tachycardia of
the heart.
“High fever greatly increases
metabolic demands and oxygen consumption and alters cellular oxygenation”
(Vera, 2013, p. 2).
– Anxiety can happen when a person
is going through something and doesn’t know how to handle it. Helping with
relaxation and medications will calm patient.
– Shock and pulmonary edema are
the most common causes of death in pneumonia
– Continuous oxygen therapy needs
to be given to her because of COPD and patient needs to be able to exchange
as much oxygen as possible when airway is cleared.
(Vera, 2013)
– Deathly complications can
develop as a side effect of therapy. It is not likely.
– If characteristics change
patient needs to report as it can mean improvement or decline into another
– Patient can spread infection so
visitors need to be limited to reduce the risk.
– Ineffective activity is a
diagnosis with someone who has a rough time breathing. Too much activity can
cause problems further than what they are experiencing.
– Symptoms of shock and or any
other complication can develop or deterioration. Any change of symptoms need
to be reported.
(Vera, 2013)
– Characteristics of pain can help
narrow down what is being felt and why. They can also tell us complications
of what is already being felt and reported.
– Comfort measures whether
nonpharmacological or pharmacological can help. Try non-pharmacological first
then result to medications.
– From pneumonia and COPD
exacerbations mouth breathing and oxygenation therapy makes dry mouth and
membranes. Oral hygiene will help with discomfort.
(Vera, 2013)

– Identify and help with behaviors
to clear airway
-Get patent airway and continue to
have one without complications.
(Vera, 2013)
-Improve ventilation and
– Teach and participate in actions
to increase oxygenation
(Vera, 2013)
– Resolution of infection
– Prevent spread of infection
(Vera, 2013)
– Control pain
– Decreased anxiety and more
(Vera, 2013)


What body system(s) will you most thoroughly assess based on
the primary/priority concern? 

Respiratory system

What is the worst possible/most likely complication to

“Sepsis/septic shock can occur when
bacteria within alveoli enter the bloodstream. Severe sepsis can lead to shock
and multisystem organ dysfunction syndrome” (Lewis et al., 2017, p. 502).

What nursing assessments will identify this complication
EARLY if it develops?

rapid heart rate, rapid breathing, low BP, altered mental status, edema, high
glucose without diabetes. (Lewis et al., 2017, p. 1591)

What nursing interventions will you initiate if this
complication develops?

assess ABC’s first. If patient goes unresponsive and there is no signs of life,
CPR must be started. If responsive still monitor ABC’s, give high flow oxygen,
prepare for intubation, make sure previous IV access is patent clean dry and
intact. Labs need to be drawn; CBC, BMP, ABG’s to assess patient’s status. Start
medications as ordered by physician including antibiotics to take care of
bacteria. Continuously monitor vitals, labs, and urine output. (Lewis et al.,

What psychosocial needs will this patient and/or family
likely have that will need to be addressed?

Fear, anxiety, agitation, depressed,

How can the nurse address these psychosocial needs?

patient needs to know that all emotions are acceptable when in a situation like
this. Explaining the situation and how things will go to the family may calm
the family and patient. Keeping a calm environment and making communication
important may help ease some emotions. The family needs to know that they have
to communicate their thoughts and feelings. Without communication feelings will
be bottled up and things can get out of hand. Family needs to be included in
all aspects of care the patient is not alone in this.

What is the patient likely experiencing/feeling right now in
this situation?

patient is an older woman who has had COPD for a while now. She probably knows
the extent of her illness but pneumonia and possibly acidosis may be new to
her. She is probably fearful and anxious. As the nurse we need to make sure she
has all the information she can get and everything is explained fully.

What can you do to engage yourself with this patient’s
experience and show that she matters to you as a person?

patient information, comfort, encourage communication, perform skills
competently, ask questions, and educate.

What did I learn from this scenario?

learned a lot from this scenario including labs and more signs and symptoms
with COPD, pneumonia, and acidosis. Airway breathing and circulation no matter
what the condition or system those are always most important. I also didn’t
know about lactate and how it connects with other labs and what it could
possibly point towards.

How can I use what has been learned from this scenario to
improve patient care in the future?

scenario really made me realize how important labs are in any condition that
could be happening. No matter how small the task or order they are all
important. Critical thinking and analysis are important in nursing care.
Knowing that the patient came in with COPD exacerbation and easing the breathing
is more important then IV access for medications. I’m glad that the DuoNeb was
made as it really helps in situations like this. Didn’t think that COPD would
really turn into acidosis and could have a possible complication of
sepsis/septic shock. Things can go down hill fast.











(arterial blood gas). (n.d.). Retrieved from

Acetaminophen. (n.d.). Retrieved

Albuterol. (n.d.). Retrieved from

ATI. (2016). RN adult medical surgical nursing: Content mastery series review module
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Azithromycin. (n.d.). Retrieved

Ipratropium. (n.d.). Retrieved

Klatt, E.C. (1994-2017).
Urinalysis. Retrieved from

Levofloxacin. (n.d.). Retrieved

Lewis, S., Dirksen, S. R.,
Heitkemper, M., Bucher, L., Harding, M. M., Kwong, J. (2017). Medical-Surgical
Nursing: Assessment and Management of Clinical Problems. (10th ed.). Retrieved

Lorazepam. (n.d.). Retrieved from

Methylprednisolone. (n.d.).
Retrieved from

Prednisone. (n.d.). Retrieved from