Essay on Copd Case Study

2774 Words Dec 14th, 2015 12 Pages
Airway/Breathing (Oxygenation) Pneumonia/Chronic Obstructive Pulmonary Disease Clinical Reasoning Case Study
STUDENT Worksheet

JoAnn Walker, 84 years old

Overview

This case study incorporates a common presentation seen by the nurse in clinical practice: community acquired pneumonia with a history of COPD causing an acute exacerbation. Principles of spiritual care are also naturally situated in
this scenario to provide rich discussion of “how to” practically incorporate this into the nurse’s practice.

Concepts (in order of emphasis)

I. Gas Exchange
II. Infection
III. Acid-Base Balance
IV. Thermoregulation V. Clinical Judgment VI. Pain
VII. Patient Education
VIII. Communication
IX. Collaboration


I.
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One disease process often influences the development of other illnesses. Based on your knowledge of
pathophysiology, (if applicable), which disease likely developed FIRST that then initiated a “domino effect” in
their life?
 Circle what PMH problem likely started FIRST
 Underline what PMH problem(s) FOLLOWED as domino(s)
II. Patient Care Begins:

Current VS: | WILDA Pain Scale (5th VS): |
T: 103.2 (oral) | Words: | Ache |
P: 110 (regular) | Intensity: | 3/10 |
R: 30 (labored) | Location: | Generalized over right side of chest with no radiation |
BP: 178/96 | Duration: | Intermittent-lasting a few seconds |
O2 sat: 86%6 liters n/c | Aggreviate:Alleviate: | Deep breathShallow breathing |
What VS data is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT VS Data: | Clinical Significance: |
Temperature, pulse, respirations, blood pressure, O2 sat, location of pain, and what aggravates and alleviates pain. | The temperature is high which signifies infection. Pulse is also high which could be due to infection, fever or anxiety. Respriations are very high and O2 is very low this is a main concern, she is not getting enough oxygen into her system and can become hypoxic and go into resp acidocis. Blood pressure is elevated and she has a history of elevated BP and heart failure so it needs to be monitored. Patient is in pain and…

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