Chelsea Williams

NRSG 110

Case Study #23

1. Identify four priority areas to include in your assessment.

a. Vital signs which will include temperature and O2 stats
b. Auscultation of lung sounds
c. Past medical and health history including medications that he takes at home.
d. Fluid intake and output.
2. Which of these assessment findings are significant? State your rationale.
a. Blood pressure is significant because it is slightly higher than normal.
b. The heart rate is abnormal because normal heart rate is 60-100 bpm. CK’s heartrate is

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105, which could mean stress on the heart, along with the increased BP.

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c. Respiration are normally around 12-20. CK’s respirs are at 32, which means the lungs are

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being overworked. Also the coarse crackles could be indicative of fluid build up in the

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lungs.

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d. CK is also running a temp of 103 F. This is indicative of an infection, and is consistent with
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the pneumonia diagnosis.
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e. His SpO2 is 84%, which is significantly less than the normal. This means that he is not
getting enough oxygen to the tissues.
3. You obtain orders from the physician. Outline a plan of what you need to do in the next 2 to 3
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hours.
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a. First, the nurse will need to order CK’s chest x-ray because it is ordered for now.
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b. The nurse will then be able to obtain her labs, so his CBC, blood culture, and sputum
culture.
c. The nurse can then start an IV for the normal saline, and administer the nebulizer
treatment.
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d. After the neb treatment, O2 can be administered with the rest of his medication.
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4. Is the IV fluid D5 ½ NS appropriate for C.K.? State your rationale.

a. This IV fluid is appropriate for CK because it is a hypertonic solution. This means that it is
able to pull out the extra fluid from the interstitial spaces that cause edema. This can
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help decrease the amount of fluid in the lungs.

5. What is the rationale for ordering O2 to maintain SpO2 over 90%?
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a. Any time there is a low SpO2, there can be disruption in the normal functions of vital
organs such as the liver and brain. Ensuring that the O2 saturation is above 90% is also
ensuring the integrity of those organs.
6. What is a C&S test, and what role will blood and sputum cultures play in CK’s care?
a. A culture test is where they incubate the specimen to determine what type of bacteria is
grown. A sensitivity test is where they can test different antibiotics to that bacteria to
determine what can best eradicate it. This is vital for CK’s care because it will help the
physician determine what antibiotic will be most effective for CK’s treatment.
7. What would you expect the CXR results to reveal?

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 a. Since it has already been determined that CK has pneumonia, you can expect to see that
the left lower lobe has increased density due to the lack of air being transported to that
portion of the lungs.
8. You need to follow a specific protocol when obtaining peripheral blood cultures. Place in order
the steps you will perform.
a. 1. - 4
b. 2. - 1
c. 3. - 3
d. 4. - 2
e. 5. - 6
f. 6. - 5
9. 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?
a. 150 mL/h

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10. How will you ensure that the home medication list is accurate?

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a. The best way to make sure that the home medication list is accurate is by asking the

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patient why he takes every single one of them. So his metoprolol treats his

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hypertension, amlodipine treats his coronary artery disease, Lisinopril helps with his
survival rate after a previous MI and can also act as an antihypertensive, furosemide

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decreases the fluid that is associated with edema and can lower BP, metformin and
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glipizide are correct because he is diabetic. Knowing the actions and reasons why he is
taking these medications ensures that the home medication list is accurate.
11. Is CK recovering as expected? Defend your response.
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a. CK is recovering as expected because his vitals have improved. Pneumonia does not go
away in one day, therefore, while CK still needs treatment, the simple fact that he is
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improving in general means that he is recovering at a pace that is suited to his situation.
12. Based on your evaluation of CK, write an outcome to achieve by the end of your shift, then list
six priority interventions you will perform toward achieving this goal.
a. An outcome to be achieved by the end of my shift would be for the patient to have more
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abilities to aid in his treatment through increased knowledge and medications.

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i. The first is to elevate the head of the bed to decrease pressure on his
diaphragm. This promotes deep breathing without the use of accessory muscles.
ii. CK should then be taught how to deep breath. Deep breathing can help release
the excretions that have been built up in the lungs and can also ensure oxygen
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can be brought into the tissues.

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iii. If CK is unable to cough up completely his secretions, a suction can be used so

that the secretions are not pulled back into the lungs.
iv. Keeping CK hydrated is of concern. Pushing fluids can help the body push out
the secretions.
v. Respiratory therapy should continue with nebulizer treatments as this promotes
the secretions to be pushed out of the lungs.
vi. Bronchodilators and analgesics should be continuously given to decrease CK’s
pain and also prevent bronchospasms.
13. By the end of your shift, which of the following assessment findings would best indicate that CK
is responding to therapy?
a. D

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 14. You know that CK is at increased risk for contracting another CAP infection. Describe four
strategies for preventing CAP infections you will include in CK’s discharge teaching plan.
a. Tell CK to get the pneumonia vaccine, which can help decrease his chances of
reoccurrence.
b. Explain the importance of hand hygiene.
c. Tell him to avoid being around people who smoke as this can cause stress on the lungs.
d. Explain how because of his immunosuppressant disorders, to be cognizant of people
who are sick around him.
15. CK 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?
a. I would tell CK that we have his infection under control and that he is in good hands. I
would also use this opportunity as a teaching moment to tell him that pneumonia is
preventable and as long as he follows the instructions from the discharge teaching plan,
his risk for developing pneumonia again has decreased.

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16. What are some community resources from which CK may benefit?

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a. The American Lung Association is full of information and resources for CK to use. Also,

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the Mayo Clinic is a great online tool with information as well.

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