Video Case Study - Caring for Patients With Bacterial Pneumonia

Nurse Jodie works on a medical-surgical unit and is caring for Ann, 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 Jodie goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Ann’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Jodie recognizes important cues including Ann’s vital signs, which are temperature 101.5 F or 38.6 C, heart rate 100 beats per minute, respirations 21 breaths per minute and regular, blood pressure 105/68 mmHg, and oxygen saturation 90 percent on room air.

Upon auscultation, Nurse Jodie notes coarse crackles and slight wheezing. Nurse Jodie also observes that Ann can’t speak in full sentences without becoming short of breath.

Next, Nurse Jodie analyzes these cues. Nurse Jodie reviews the electronic health record, or EHR, and notes Ann’s WBC count is elevated at 12,500 cells per mm3.

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

Nurse Jodie recognizes that Ann needs effective respiratory management. Next, using the information she has gathered along with Ann’s medical history, Nurse Jodie discusses her findings with RN Seth, and they choose a priority hypothesis of ineffective gas exchange.

Then, they generate solutions to address Ann’s infection that will include pharmacologic and nonpharmacologic interventions.

They establish the expected outcome that after intervening, Ann will maintain an oxygenation saturation above 92 percent during the shift.

Nurse Jodie then takes action to implement these solutions. Nurse Jodie: 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.

Ann: Okay, I hope it helps. Nurse Jodie: 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.

Ann: Okay. Nurse Jodie administers the acetaminophen according to the principles of safe medication administration.

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

Nurse Jodie then dims the lights and gives Ann the call button. Before she leaves the room, Nurse Jodie ensures that the antibiotic and fluids are infusing properly.

Three hours later, Nurse Jodie 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 beats per minute, respirations 21 breaths per minute and regular, blood pressure 112/68 mmHg, and her oxygen saturation is 94 percent on 2 liters of oxygen per nasal cannula.

Ann is also now able to speak in full sentences. Nurse Jodie: How are you feeling, Ann?

Ann: A little bit better. Nurse Jodie: That’s great!

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

Ann: No, my doctor offered it to me when I got my flu shot, but I didn’t want it. Nurse Jodie: 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. Ann: Okay, thanks.

Alright, as a quick recap… Nurse Jodie recognized and analyzed cues related to Ann’s ineffective gas exchange and, in collaboration with RN Seth, prioritized hypotheses and generated solutions to address this problem.

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

Since Ann’s oxygen saturation goal was achieved,