67 y.

o
Caucasian
Male
ADMITTED THROUGH THE ED
WITH DYSPNEA AND COUGH

Medical History
Coronary artery disease

Bacteremia

Hypertrophic obstructive
cardiomyopathy

Hypertension

Chronic kidney disease

Parkinsons disease

Hyperlipidemia

Psoriasis

Obstructive sleep apnea

Psoriatic arthritis

Atelectasis and respiratory

insufficiency

Diabetes

Bipolar
Endocarditis

Peripheral neuropathy

Medical data
The patient does not have an
official admitting diagnosis.
However, the plan of care is
empiric treatment for Pneumonia.
The patient has no previous
history of Pneumonia. He does
have a history of respiratory
insufficiency and has obstructive
sleep apnea.

Pathophysiology

(Ignatavicius, Workman, 2013, pg.

647)

Pneumonia is a build up of fluids in a lung(s)

from an inflammatory process.
The inflammation can be triggered by
bacteria, viruses or something irritating that
has been inhaled.
An organism will infiltrate the mucosa of the
airway and seek to multiply in the alveoli.
WBCs will travel to the infection site which
then causes the capillaries to leak, edema and
produce exudate.
The fluids will collect and the alveoli wall will
thicken.
This will reduce the exchange of gases and
cause hypoxia.

Bacteria
infiltrates
lung
mucosa
Reduced
gas
exchange
and
hypoxemia

This fluid
build up
causes
alveoli
walls to
thicken

WBCs
travel to
the site of
infection

This
causes
capillaries
to leak,
edema and
exudate

Diagnostic & Lab data

Cl 108 <Cardiac decompensation, Kidney
dysfunction>
BUN 21 <Kidney damage, dehydration>
Alb 2.4 <Renal disorders, prolonged immobility,
malnutrition>
Hgb 11.5 <Kidney diseases, Anemia>

CXR
showing
normal
lungs

Hct 33.6 <Chronic kidney failure, Anemia>

Plt 132 <Zithromax>
PT 15.9 <Heart failure, Warfarin>
BNP 115 <Heart failure, left ventricular
hypertrophy, myocarditis, renal failure>
eGFR 67 <Chronic kidney disease>
CXR shows possible atelectasis and PNA. Doctors
want to rule out PNA clinically.

CXR
showing
Pneumoni
a

Physical
Assessmen
t

Nursing Assessment
Respiratory
RR: 19, labored
Lung Fields
Wheezing present in all fields
during expiration
Diminished lung sounds in right
lower lung field

O2 Sat: 95% on RA
O2 ordered PRN

Unproductive cough

Nursing Assessment
Circulation
BP: 118/74
HR: 79, strong & regular
Edema: +2 pitting in BL LE
Pedal Pulses: Palpable, but weak
on right foot
Capillary refill: 3-seconds
Mucous membranes: Moist, pink
Telemetry: Sinus rhythm (SR)

Nursing Assessment
Neurologic
A&O x3
Poor historian
Wife in room to answer health
hx questions

Limited sensation (&

weakness) in BL LE
PERRLA

Nursing Assessment
Integumentary
Pink in color; cool to touch
Dry with scaling from psoriasis
More extensive on BL feet

Braden Score: 12
High Risk

Stage 1 gluteal cleft decubitus ulcer

IV: Left AC 20g NS @ 125 mL/hr
Dressing dry & intact with tape &
transparent dressing
No signs of redness or swelling, cool to
touch

Nursing Assessment
Elimination
Urinary incontinence
Incontinent briefs: 2-3 with
minimal output in each
BM: 4-days ago
Normally 1x/day

Bowel sounds: Active, all

four quadrants
Abdomen: Firm upon
palpation

Nursing Assessment
Nutrition
More than body requires
Unintentional wt. gain

Ht.: 59
Wt.: 250#
BMI: 36.9
Increased abdominal adiposity
Diet: ADA

Nursing Assessment
Mobility
Limited ROM
Unsteady gait & balance
Peripheral neuropathy

Strength: BL weak, upper &

lower
Hand grip
Leg muscles

Assistive Devices
Wheelchair

Nursing Assessment
Activity & Self-Care
Dependent
Toileting
Bathing
Dressing
Walking (wheelchair bound)
Stairs
Laundry
Shopping
Housecleaning

Partial Assist
Feeding
Medications

Nursing Assessment
Comfort & Rest
Pain: 3-4 level
Location: Low back (since
admission)
Quality: Ache

Sleep patter: 8-10 hr/day

Evening nap

No sleeping concerns

Nursing Assessment
Psychosocial & Spiritual
Diminished communicative
cognition since 2013 (per wife)
Can I slap your bottom?

Presents with diminished

problem solving & abstract
reasoning
Responds in two to three words at
a time.
Short attention span/distracts
easily.

Nursing Assessment
Miscellaneous
Safety & Security
Wife is support system

Loving & Belonging

Spouse

Self-Esteem
Ego Integrity vs. Despair

Medication
s

The Data

The Study
With the MR30 strain, all the
treatments increased the rate
of sterile blood cultures with
respect to the controls
The high dose of vancomycin
was better than the low dose
(100% versus 64.3%).
With MR33, linezolid and high
dose vancomycin increased the
sterile blood cultures compared
with the controls (93.3% and
100% versus 40%)

VS.
The high dose was superior to
the low dose of vancomycin
(100% versus 66.7%).
Although the treatment
duration chosen for the model
is shorter than the time
required to treat pneumonia in
the clinical setting, 72 hours is
sufficient to observe significant
differences in the bacterial
burden in lungs related to the
antimicrobial treatments.
J. Antimicrob. Chemother. (2012) 67 (8): 1961-1967.

Medication PRN
Acetaminophen (Tylenol)- 650mg - Analgesic
Bisacodyl Suppository (Dulcolax) 10mg Constipation
Dextrose 50% (D50W) 25ml Hypoglycemia
Glucagon (human recombinant) 1mg Hypoglycemia
Insulin Lispro (Humalog) 0-4U Diabetes Mellitus
Ondansetron (Zofran-ODT) 4mg Anti-emetic
Polyethylene Glycol (Glycolax) 17g - Constipation

Scheduled medications
Albuterol (Proventil) 2.5mg Bronchodilator
Aripiprazole (Abilify) 2.5mg Bipolar/Depression
Aspirin 81mg Prophylactic for Myocardial Infarction
Atrovastatin (Lipitor) 20mg Hypercholesterolemia
Azithromycin (Zithromax) 500mg Anti-infective
Carbidopa-levodopa (Sinemet CR) 1 tablets AntiParkinson
Carbidopa-levodopa (Sinemet) 2 tablets AntiParkinson
Cefepime (Maxipime) - 1g Anti-Infective

Scheduled Medications (cont.)

Cetirizine (Zyrtec) 10mg - Antihystimine
Choldcalciferol (Vitamin D3) 2,000U Supplement
Cyanocobalamin (Vitamin B12) 1,000U Supplement
Donepezil (Aricept) - 10mg Cognitive Function
Duloxetine (Cymbalta) 60mg Peripheral Neuropathy
Enoxaparin (Lovenox) 1mg/kg - Prophylactic DVT
Ferrous Sulfate 325mg Iron deficiency anemia
Folic Acid (Folvite) 1mg Folic acid deficiency

Scheduled Medications (cont.)

Insulin Detemir (Levemir) 20U - Diabetes Mellitus
Ipratropium-Albuterol (Duo-Neb) 3ml Bronchodilator
Lisinopril (Prinivil, Zestril) 2.5mg Antihypertensive
Metoprolol (Lopressor) 50mg Antihypertensive
Multivitamin (Theragran) 1 tablet Supplement
Ondansetron (Zofran-ODT) 4mg Anti-emetic
Topiramate (Topamax) 50mg Bipolar

Scheduled Medications (cont.)

Tramadol (Ultram) 100mg Analgesic
Vancomycin (Vancocin) 1,250mg Antibiotic
Warfarin (Coumadin) 2mg Anticoagulant
Warfarin (Coumadin) 1mg Anticoagulant

Therapeutic
procedures
DRUG THERAPY
Antibiotics
RESPIRATORY ASSESSMENT
ORAL CARE
RT
Ipratropium-Albuterol nebulizer q4
CPAP at night when sleeping
PT
OT
*REST ARE IN NS INTERVENTIONS*

THE IMPORTANCE OF ORAL HYGEINE IN

PREVENTING PNEUMONIA IN THE
HOSPITALIZED PATIENT
i.

Deterioration of oral health in

hospitalized patients puts him/her
at risk for a HAI that could possibly
lead to PNA.

ii. Studies show that dental plaque

houses bacteria that have been the
causative agent in patients who
have healthcare acquired
pneumonia.
iii. Proper, routine oral care for
hospitalized patients have reduced
the incidence of healthcare
acquired pneumonia.
(Quinn et al. 2014, pg. 13)

#1. Decreased cardiac output RT altered

contractility AEB cough, dyspnea, weak
peripheral pulses, edema in lower
extremities, weight gain, decreased urine
output and change in mental status.
Goal: Patient will have decreased edema to +1 or better within 24 - 48 hours.
Interventions: Monitor I&O & daily weights
Apply SCDs and compression stockings to lower extremities
Check blood pressure before administering cardiac medications
Monitor edema using the +1 to +4 scale.
Evaluation: Patients output is much less than his input and it hasnt changed.
Edema in the lower extremities is still at +2. BP was within normal limits before
giving cardiac medicines. Continuing to monitor pt. The doctor has been notified.

#2. Excess fluid volume RT cardiac

dysfunction and renal failure AEB edema +2
in lower extremities and pt low urine output.
Goal: Patient will maintain urine output of >60ml/hr within 2 days.
Interventions: Provide a restricted sodium diet as ordered and ensure adequate
protein intake.
Monitor electrolyte levels closely
Monitor patients behavior for restlessness, anxiety or confusion, use safety
precautions is symptoms are present.
Evaluation: Patient is on a heart healthy diet and is eating under 2g of sodium a
day and is eating protein with every meal. Electrolytes are within accepted range
except for Cl-, which is slightly elevated. Blood to be drawn again in the AM for a
CMP.

#3. Ineffective breathing pattern RT loss of

functional lung tissue & obesity AEB CXR
shows visible atelectasis and patient grunts
Goal:on
Patient
will maintain an effective
breathing
while breathing and wheezing
expiration.
pattern AEB normal RR and depth with absence of dyspnea & wheezing within 24
hours.
Interventions: Administer O2 as needed
Monitor RR, ease and depth of respirations
Note use of accessory muscles, nasal flaring, retraction, irritability confusion or
lethargy
Auscultate breath sounds & ensure RT gives patient his breathing treatment q4
Monitor pulse oximetry & keep patient bed elevated
Educate the patient on pursed lip breathing and controlled breathing techniques.
Evaluation: Patient has not needed O2 as his levels have been above 95%. He is
slightly short of breath but it seems to be more from his obesity at this point in
time but his RR are within normal limits. He is still grunting when breathing so I
asked him to take a few deep breaths and cough a few times to help open alveoli.
Wheezing on expiration was diminished after RT treatment.

 Impaired physical mobility RT high BMI, peripheral neuropathy,

neuromuscular impairment and sedentary lifestyle.
Impaired skin integrity RT mechanical factors, physical
immobilization AEB stage 1 pressure ulcer on tail bone,
psoriasis dry patches throughout body (mostly on feet) and
slow skin healing due to diabetes.
Activity intolerance RT immobility and sedentary lifestyle AEB
patient needs assistance with 95% of self-tasks, cant move his
own legs, can barely use his arms with minimal strength and
he needed four people to move him onto a stretcher to be
taken down for tests.
Impaired walking RT obesity, neuromuscular impairment AEB
patient unable to move legs on his own and he was unable to
feel me move his legs.
Impaired urinary elimination RT urinary obstruction AEB
incontinence.
Impaired verbal communication RT alteration in the central
nervous system AEB difficulty forming sentences, inappropriate
verbalization, and difficulty in comprehending usual
communication pattern.
Acute pain RT lack of movement in bed, and uncomfortable
bed AEB patient reports a pain of 3 or 4 in his lower back that
started after he got to the hospital.
Impaired comfort RT patients inability to move in bed due to
obesity AEB inability to relax, tense, drowsy from lack of
comfort and reports being uncomfortable.
Interrupted family processes RT modification in family finances

Nursing
diagnoses

Health
promotion,
Cultural &
Development
al
consideration
s.

American Culture
American culture has been prone to many
illnesses such as obesity due to poor food choices.
Such as fast, greasy and processed food, this has
contributed to chronic diseases in the elderly.
Patient has developed hyperlipidemia, diabetes,
obstructive sleep apnea, and CAD which could be
the result of his obesity.
Patient weights 250lbs and his height is 59.
Patient is on a heart healthy diet and is eating
under 2g of sodium a day and is eating protein in
every meal.
He has limited mobility due to obesity, and
peripheral neuropathy.
Patients obesity has contributed to his respiratory
problems.

Health promotion
Obesity is a major public health problem in the United
States, and its the cause of major complications in the
cardiovascular and respiratory system. Obesity has been
associated with a 36% increase in health care spending,
and treating the obese patient can be medically
challenging (Obesity- Health issue).
Obesity is defined as body mass index of 30 or above.
The patients BMI is 36.9 due to his sedentary lifestyle,
he is obese and he needs assistance with at least 95%
of his ADLs. The patient also has difficulty breathing due
to his weight.

Developmental Considerations
67 year old Male, Caucasian
Erickson Stage: Ego Integrity vs. despair. The work of this stage is to
accept ones life as meaningful.
As we grow older change is more prevalent and chronic illness becomes
more critical. Excess weight can also cause degeneration of the
musculoskeletal system, especially the joints.
Obese people are also more susceptible to infections and infectious
diseases tend to heal more slowly.
Patient is at risk for constipation due to insufficient physical activity.
Patient has impaired skin integrity related to physical immobilization.

Health Promotion
Suggests an initial exercise program
that consist of a short 10 min/day,
which gradually increases to 30
minutes/day.
Planning food intake for each day
Self-monitoring of food intake,
including keeping a food and exercise
diary.
Controlling stimuli that cause
overeating, such as watching

Common complications R/T

obesity.
Type 2 diabetes mellitus
Hypertension
Hyperlipidemia
Coronary Artery Disease
(CAD)
Stroke
Peripheral artery disease
(PAD)
Obstructive Sleep apnea
Obesity hypoventilation
syndrome
Metabolic syndrome
Depression and other
mental health/behavioral
health problems
Urinary incontinence

Coordination of Care
Occupational Therapy
Supporting health and well-being
Empowering individuals
Promote quality of life

Respiratory Therapy
Breathing Treatment

Occupational Therapy
ADLs

Home modifications to
promote activity
participation

Progressive Increase in
Activity Tolerance

Planning for healthier

choices (Food Selection)

Safe household and

community mobility

Relaxation and Sleep

routines

Body Mechanics for

activities and transfers

Coping with pain, stress and

anxiety within a social
context

Monitoring and Managing

Skin Integrity

Sexual Health (expression,

communication, positioning

Patient Teaching
Repositioning in Bed (Pressure ulcers, Low back pain and
lung fluid)
SCDs and Compression stockings
Nutrition
Importance of Water

 Including clients significant other

in teaching. Focus on five key
points of cardiac discharge
teaching
Daily weight monitoring
Symptom recognition
Heart Healthy Eating
Medication and adherence to regimen
Routine check-ups

Discharge
Planning/
Patient Teaching
Decreased cardiac output RT altered
contractility AEB cough, dyspnea,
weak peripheral pulses, edema in
lower extremities, weight gain,
decreased urine output and change
in mental status

 Daily weight monitoring and

reporting
Fluid and sodium restriction. Help
plan schedule with client and family
for fluid intake. Refer to dietitian for
low-sodium diet.
Teach how to monitor intake and
output.

Discharge
Planning/
Patient Teaching
Excess fluid volume RT cardiac
dysfunction and renal failure AEB
edema +2 in lower extremities and
pt low urine output.

 Pursed-lip breathing (improves

respiratory function)
Progressive relaxation (during
episodes of dyspnea)
Consult Occupational Therapy for
energy conservation techniques

Discharge
Planning/
Patient Teaching
Ineffective breathing pattern RT loss
of functional lung tissue AEB CXR
shows visible atelectasis and pt
grunts while breathing.

Using Your Noggin

A 67 y.o. obese pt. with a hx of DM, HTN, and CRF has

+2 pitting edema in his BL lower extremities and
wheezing in all lobes. The HCP has written an order to
administer a loop and thiazide diuretic. Which of the pt.
lab values would the prudent nurse want to look at first?
A.
B.
C.
D.

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