Case study - Community-acquired pneumonia: Nursing

Nurse Jody works on a medical surgical unit and is caring for an a 44 year old with a history of smoking, who was recently admitted for community acquired pneumonia.

In collaboration with the registered nurse, RN Seth. Nurse, Jody goes through the steps of the clinical judgment measurement model to make clinical decisions about ans care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action and evaluating outcomes.

First, nurse, Jody recognizes important cues including Ann's vital signs which are temperature 101.5 °F or 38.6 °C, heart rate, 100 BPM, respirations, 21 breaths per minute and regular BP.

105/68 millimeters of mercury and oxygen saturation. 90% on room air upon auscultation.

Nurse, Jody notes coarse crackles and slight wheezing nurse. Jody also observes that Anne can't speak in full sentences without becoming short of breath.

Next, nurse Jody analyzes these cues. Nurse Jodi reviews the electronic health record or E hr and notes Ann's white blood cell count is elevated at 12,500 cells per cubic millimeter.

Nurse, Jodi knows that an infection is likely causing inflammation in Ann's lungs. This can result in fluid entering anne's alveoli which can impair gas exchange as well as a narrowing of her airways which can interfere with her breathing.

Nurse. Jodi recognizes that Anne needs effective respiratory management.

Next, using the information she has gathered along with Ann's medical history. Nurse, Jody discusses her findings with RN set and they choose a priority hypothesis of ineffective gas exchange.

Then they generate solutions to address ans infection and will include pharmacologic and nonpharmacologic interventions.

They established the expected outcome that after intervening and will maintain an oxygenation saturation above 92% during the shift.

Nurse, Jody then takes action to implement these solutions. Nurse Jody says I'm going to give you some oxygen to help you breathe a little easier.

This plastic tubing will go around your ears and the prongs will go into your nose. It's important that you breathe in through your nose.

So the oxygen will go into your lungs and responses. Ok?

I hope it helps your health care provider. Also ordered an antibiotic called Ciprofloxacin some fluids to go through your IV and these acetaminophen tablets to help with your fever.

Ok. Nurse Jody administers the acetaminophen according to the principles of safe medication administration.

Then as RN Seth administers the IV antibiotic and fluids. Nurse Jody assists Anne to a position of comfort and provides her with a cool pack for her forehead.

Nurse, Jody then dims the lights and gives Anne the call button before she leaves the room. Nurse, Jody ensures that the antibiotic and fluids are infusing properly.

Three hours later, Nurse Jody enters Ann's room to evaluate the outcomes of her actions. She takes Ann's vital signs which are temperature 99.1 °F or 37.3 °C heart rate, 84 BPM, R 21 breaths per minute and regular BP.

112/68 millimeters of mercury and her oxygen saturation is 94% on 2 L of oxygen per nasal cannula. Anne is also now able to speak in full sentences.

Nurse Jodi asks, how are you feeling an ann responds a little better? That's great.

I also wanted to ask you about a pneumonia vaccination. Have you ever received one?

No, my doctor offered it to me when I got a flu shot, but I didn't want it. Well, we can give it to you while you're here after you're feeling better.

It'll help prevent you from getting pneumonia again in the future. OK.

Thanks. All right.

As a quick recap, nurse Jody recognized and analyzed cues related to Ann's ineffective gas exchange and in collaboration with R and set prioritized hypotheses and generated solutions to address this problem.

Nurse Jody and RN Seth then implemented interventions to address and evaluate Ann's outcomes and compared them to the expected outcome.

Since Ann's oxygen saturation goal was achieved, they determined that the plan of care was successful.