Pneumonia Case Study: Group Activity
A 50 year old white female presents to the Emergency Room with complaint of fever of
102 at home, diaphoresis, dyspnea, and cough, occasionally productive yellow sputum.
Patient has a history of COPD, Multiple Sclerosis, and was a smoker until 6 six years
ago.
Vital signs on admission: T 101, HR 124, RR24, BP 122/79
CXR= Consolidation LUL/RLL
EKG: Sinus tachycardia at 118 bpm
Labs: WBC elevated at 19.7
ABG’s (on bipap): ph 7.42, pCo2 39, pO2 192, sO2 98.5%
Admission orders include: Admit to CCU, cardiac monitoring, foley, oxygen at 2l/min,
IV fluids at 100cc/hr, Duoneb NMT’s QID & q2 hrs prn, IV Rocephin 1gm daily, IV
Zithromax 500mg daily, IV Levaquin 500mg daily, SQ Lovenox 30mg daily, blood
cultures, sputum cultures, daily chest x-rays.
List three items you would assess:
1) Lung Sounds/ oxygen saturation
2) Cough present & if productive
3) Pain, confusion (mental status)
List two topics for education:
1) Positioning/C&DB
2) Increase fluid intake
List two Nursing Diagnosis:
1) Ineffective breathing pattern
2) Ineffective airway clearance
3) Acute pain d/t inflammation…………………..