Assignment: Case Study 30
H.K’.s sister has brought her 71 year-old brother to the primary care clinic because he has had
a fever for 2 days. She says he has chills and a productive cough and he cannot lie down to
sleep because “he can’t stop coughing.” After H.K. is examined, he is diagnosed with
community-acquired pneumonia (CAP) and admitted to your floor at 1130. The resident is bussy
and asks you to complete your routine admission assessment and call her with your finding.
1. Name 4 priority areas to include in your assessment.
○ Check for airway patency
○ Ascultate lung sound
○ Check oxygen saturation
○ Obtain other vital signs such as blood pressure, temperature, heart rate and
asses his pain
Your assessment findings are as follow: H.K.’s vital signs are 154/82, 105, 32, 103 degree
fahrenheit , Spo2 84% on room air. You auscultate decreased breath sounds and coarse
crackles in the left lower lobe anteriorly and posteriorly. His nail beds are dusky on fingers and
toes. He has cough productive of rust colored sputum and complains of pain in the left side of
his chest when he coughs. He is lifetime nonsmoker, his medical history includes coronay artery
disease and myocardial infarction with a stent. He is currently on metoprolol, amlodipine,
lisinopril, and furosemide; for his type 2 diabetes mellitus, he is taking metforming and glipizide.
He has never gotten a pneumococcal or flu vaccination. He does not report getting hived when
he took an anitibotic pill a few years ago but does not remember the name of the antibiotic
2. Which assessment findings are significant? Give your rationale
● Spo2 of 84% is significant because it indicates low oxygen level and when there
is not enough oxygen in the body, it will cause damage to the individual organs
especially the heart and brain and this can be fatal
● Decrease in breath sounds and crackles in the lungs is abnormal because it is
indicating the collapsed of the alveoli and this condition will greatly disrupt the
gas exchange leading to low oxygen
● The respiration is high, blood pressure is high, and dusky nails beds indicates
abnormality; these condition are sign of low oxygen
● The body temperature is high (fever) and this indicate infection
● The patient’s medical history such as heart disease and diabetes puts him at a
higher risk for infection
Admission orders
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Consistent carbohydrate diet
VS q2hr
IV D5 ½ NS at 125 ml/hr
Ceftriaxone 1 gram every 12 hours
albuterol 2.5mg/ ipratropium 250 mcg nebulizer
Titrate oxygen to maintain Spo2 over 90%
Obtain sputum for C&S
STAT blood cultures & sensitivity
Blood glucose ac and hs with sliding scale regular insulin per protocol #2
CBC with differential and basic metabolic panel
CXR now and in the morning
Continue home medication
3. You obtain order from the resident. Outline a plan of what you need to do in the
next 2 to 3 hours.
○ Obtain first set of vital sign (5 minutes)
○ administer the 2.5 ml albuterol first and the ipratropium 250 mcg nebulizer
treatment to stabilize the patient’s breathing (15 minutes)
○ titrate oxygen to bring the Spo2 back up (10 minutes)
○ Collect blood for blood culture & sensitivity test, CBC, sputum for C&S and get
sent to the lab immediately (25)
○ Prepare patient for CXR (30 minutes)
○ initiate IV access to administer 1 gram of Ceftriaxone every 12 hours and D5 ½
NS at 125ml/hr (20 minutes)
○ Check blood sugar before meal (3 minutes)
○ Administer home medication if is due (15 minutes)
○ Consistent carbohydrate diet and set up the meals (15 minutes)
○ Get another set of vital sign (vital signs is taken every 2 hours)
4. Is D5 ½ NS an appropriate IV fluid for H.K? State your rationale
○ Fluid replacement is necessary for this patient because he has a fever, fast
breathing, and inflammation of the lungs can cause him to lose a lot of fluid. This
IV is the the appropriate tonicity for the patient because the patient has an
elevated blood pressure so giving an isotonic solution might make it worse.
5. What is the rationale for ordering oxygen to maintain Spo2 over 90%?
● This patient is having issue with the gas exchange due to the inflammation of the lung
tissue caused by pneumonia. Therefore, a supplemental oxygen is needed to bring his
oxygen level up and maintain it over 90%. Having enough oxygen is very important
because the tissue in each organ requires oxygen to function and if the tissues do not
get enough oxygen, they will start to get damaged and eventually die if not intervened
immediately.
6. What is the role of C&S test, and what role will blood and sputum cultures play in
H.K.’s care?
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They all play in identifying specific organim that cause the infection. Once the right
patoghens have been identified, an appropriate drugs will be prescribed which will
specifically target the pathogens cause pneumonia in H.K
7. What would you expect the CXR results to reveal?
● It will reveal white spot on the affected lungs
8. Steps to obtain peripheral blood cultures
1. Verify patient’s identity and perform hand hygiene
2. Select venpuncture site. Clease and allow to dry
3. Peform venipuncture and collect 20 ml of venous blood return
4. Inject 10 ml of blood into the anaerobic bottle
5. Inject 10 ml of blood into the aerobic bottle
6. Attach identification to specimen and send to lab within 30 minutes
9. The pharmacy sends the ceftriaxone in 100 ml 0.9% NaCl with instructions to infuse
over 40 minutes. At how many ml per hour will you regulate the IV infusion pump?
● 150 ml/h
10. How will you ensure H.K.’s home medication list is accurate?
● Ask if has a list of medication with him; use that to check for accuracy
● Ask the patient types of medication he is on
● Call his pharmacy and primary care doctor’s office to obtain his current medication upon
his consent
Case Study Progress
The next morning you are again assigned to care for H.K. Your assessment finding are as
follows : VS 154/82, 92, 26, 100 degree F, Spo2 94% on 2 L O2 per nasal cannula. He appears
to be in no apparent distress and denies any dyspnea. You asucultate decreased breath sounds
and coarse crackles in the left and complains of pain the left side of his chest when he coughs
11. Is H.K. recovering as expected? Explain you rational
● Yes. His oxygen is stable, his fever, respiration and heart rate have reduced. He denies
of any dyspnea.
12. Outcome achieved by end of the shift and intervention:
● Outcome: Patient verbalizes releive of pain at level less than 3 and less discomfort
caused by the infection
● Interventions:
○ Provide comfort measure through back rub, massage, repositioning, calm
environment
○ Encourge to increase fluid intake to help with the dry mouth and thinning the
mucous
○ Encourge patient to inform the pain soon before it becomes sever to ensure that
pain medication can be given at appropriate time
○ Provide oral hygiene
○ Provide hard candy to suck on for dry mouth
○ Limit physical activity that make the breathing harder
13. Bye the end of the shift, which assessment finding would best indicate that H.K. is
responding to the therapy?
● The correct option is A (cough productivity of yellow sputum; lung sounds clear; Spo2
96% on room air
14. Describe 4 strategis for preventing CAP infections including in H.K.’s discharge
teaching plan
● Get pneumococcal vaccine and the yearly flu vaccine
● Washing hands regularly
● Avoid crowd and people who have cold or flu
● Practice healthy lifestyle such as eating and drinking healthy, get enough rest, moderate
excersice daily
15. H.K. confides in you, “you know, my wife dies a year ago, and I live alone now. I’ve
have thinking… this pneumonia stuff has been a little scary.” How will you respond?
● Listen and acknowledge his feelings. Encourage him to freely express his thought and
feeling about things that are bothering him.
16. What are some communit resource from which H.K. Many benefit?
● Local senior center
● Local public library
● Community care service program
● Aging resource connection