Scenario The sister of C.K. brought her 71-year-old brother to
Scenario
The sister of C.K. brought her 71-year-old brother to the primary care clinic after he came down with a fever 2 days ago. She said he has shaking chills, a productive cough, and he can’t lie down to sleep because “he can’t stop coughing.” After C.K. is examined, he is diagnosed with community-acquired pneumonia (CAP) and admitted to your floor.
1. Identify the eight most important things to include in your assessment.
Your assessment findings are as follows: C.K.’s vital signs are 154/82, 105, 32, 103° F (39.4° C), SaO2 84% on room air. You auscultate decreased breath sounds in the left lower lobe anteriorly and posteriorly and hear coarse crackles in the left upper lobe. 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. C.K. seems to be well nourished and adequately hydrated. He is a lifetime nonsmoker. Past medical history includes coronary artery disease and myocardial infarction (MI) with a stent; he is currently on metoprolol (Lopressor), amlodipine (Norvasc), lisinopril (Zestril), and furosemide (Lasix); for his type 2 diabetes
mellitus, he is also taking metformin (Glucophage) and rosiglitazone (Avandia). He has never gotten the Pneumovax or flu shot. He does report getting “hives” when he took “an antibiotic pill” a few years ago but doesn’t remember the name of the antibiotic.
2. Which of these assessment findings concern you? State your rationale.
HCP’s Orders
2100-Calorie ADA diet
VS with temperature q2h
IV of D5½ NS at 125 mL/hr
Ceftriaxone (Rocephin) 1g IV bid
Metaproterenol sulfate (Alupent) 0.4% nebulizer treatment q3h
Titrate O2 to maintain SaO2 over 90%
Obtain sputum for C&S
Blood cultures for temperature over 102° F (38.9° C)
CBC with differential and basic metabolic panel
Urinalysis (UA) with C&S
Chest x-ray (CXR) now and in the morning
3. Review the orders and outline a plan of what you need to do in the next 2 to 3 hours.
4. Is the IV fluid of D5½NS appropriate for C.K.? State your rationale.
5. What is the rationale for ordering O2 to maintain SaO2 over 90%?
6. What is a C&S test, and why is it important?
7. Why were blood cultures ordered to be drawn?
8. Why are blood cultures drawn from two different sites?
9. What would you expect the CXR results to reveal?
10. The pharmacy sends the ceftriaxone (Rocephin) IV 1 g in 100 mL 0.9% NaCl with instructions to infuse over 40 minutes. At how many milliliters per hour will you regulate the IV infusion pump?
11. Which of the following assessment findings would best indicate that C.K. is responding to
therapy?
a. Complaints of dyspnea; respiratory rate of 26 on 2 L oxygen; clear lung sounds
b. Cough productive of white sputum; temperature of 100.0° F (37.8° C); SaO2 98% on 2 L NC
c. Coarse crackles in posterior lower lobes; respiratory rate 22; no complaints of chills
d. Cough productive of yellow sputum; lung sounds clear; SaO2 96% on room air
C.K. recovers from his pneumonia and is preparing for discharge. You know that C.K. is at increased risk for contracting CAP infections.
12. Discuss four strategies for prevention.
13. C.K. confides in you, “You know, my wife died a year ago, and I live alone now. I’ve been
thinking . . . this pneumonia stuff has been a little scary.” How will you respond?
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