Pneumonia-COPD
Joan Walker, 84 years old
Primary Concept
Gas Exchange
Interrelated Concepts (In order of emphasis)
1.
2.
3.
4.
5.
6.
7.
Infection
Acid-Base Balance
Thermoregulation
Clinical Judgment
Pain
Patient Education
Communication
8. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
UNFOLDING Reasoning Case Study: STUDENT
Pneumonia-COPD
History of Present Problem:
Joan Walker is an 84-year-old female who has had a productive cough of green phlegm that started four days ago that
persists. She was started three days ago on prednisone 40 mg PO daily and azithromycin (Zithromax) 250 mg PO x5 days
by her clinic physician. Though she has had intermittent chills, she had a fever last night of 102.0 F/38.9 C. She has had
more difficulty breathing during the night and has been using her albuterol inhaler every 1-2 hours with no improvement
so she called 9-1-1 and was brought to the emergency department (ED) where you are the nurse who will be responsible
for her care.
Personal/Social History:
Joan was widowed six months ago after 64 years of marriage and resides in assisted living. She is a retired elementary
school teacher. She called her pastor before coming to the ED and he has now arrived and came back with the patient. The
nurse walked in the room when the pastor asked Joan if she would like to pray. The patient said to her pastor, “Yes please,
I feel that this may the beginning of the end for me!”
What data from the histories is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
RELEVANT Data from Social History:
Clinical Significance:
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect)
PMH:
Home Meds:
Pharm. Classification:
Expected Outcome:
1. Fluticasone/salmeterol
COPD/asthma
diskus 1 puff every 12 hours
Hypertension
2. Albuterol MDI 2 puffs
Hyperlipidemia
every 4 hours prn
Cor-pulmonale
3. Lisinopril 10 mg PO daily
Anxiety
4. Gemfribrozil 600 mg PO
1ppd smoker x40 years;
bid
quit 10 years ago
5. Diazepam 2.5 mg PO
every 6 hours as needed
6. Triamterene-HCTZ 1 tab
PO daily
One disease process often influences the development of other illnesses. Based on your knowledge of
pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in her life?
• What PMH problem likely started FIRST
•
Name what PMH problem(s) FOLLOWED as domino(s)
© 2016 Keith Rischer/www.KeithRN.com
Patient Care Begins:
Current VS:
T: 103.2 F/39.6 C (oral)
P: 110 (regular)
R: 30 (labored)
BP: 178/96
O2 sat: 86% 6 liters n/c
P-Q-R-S-T Pain Assessment (5th VS):
Provoking/Palliative: Deep breath/Shallow breathing
Ache
Quality:
Generalized over right side of chest with no radiation
Region/Radiation:
3/10
Severity:
Intermittent–lasting a few seconds
Timing:
What VS data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
Current Assessment:
GENERAL
APPEARANCE:
RESP:
CARDIAC:
NEURO:
GI:
GU:
SKIN:
Appears anxious and in distress, barrel chest present
Dyspnea with use of accessory muscles, breath sounds very diminished bilaterally ant/post
with scattered expiratory wheezing
Pale, hot & dry, no edema, heart sounds regular–S1S2, pulses strong, equal with palpation at
radial/pedal/post-tibial landmarks
Alert & oriented to person, place, time, and situation (x4)
Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants
Voiding without difficulty, urine clear/yellow
Skin integrity intact, skin turgor elastic, no tenting present
What assessment data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data:
Clinical Significance:
© 2016 Keith Rischer/www.KeithRN.com
12 Lead EKG
Interpretation:
Clinical Significance:
Chest x-ray:
What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Results: Clinical Significance:
Left lower lobe infiltrate.
Hypoventilation present
in both lung fields
Lab Results:
What lab results are RELEVANT that must be recognized as clinically significant to the nurse?
Complete Blood Count (CBC)
WBC (4.5–11.0 mm 3)
Hgb (12–16 g/dL)
Platelets(150–450x 103/µl)
Neutrophil % (42–72)
Band forms (3–5%)
Current
14.5
13.3
217
92
5
High/Low/WNL?
Previous:
8.2
12.8
298
75
1
What lab results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Lab(s):
Clinical Significance:
TREND: Improve/Worsening/Stable:
© 2016 Keith Rischer/www.KeithRN.com
Basic Metabolic Panel (BMP:)
Sodium (135–145 mEq/L)
Potassium (3.5–5.0 mEq/L)
CO2 (Bicarb) (21–31 mmol/L)
Glucose (70–110 mg/dL)
BUN (7–25 mg/dl)
Creatinine (0.6–1.2 mg/dL)
Misc. Labs:
Lactate (0.5–2.2 mmol/L)
Current:
138
3.9
35
112
32
1.2
High/Low/WNL?
3.2
Prior:
142
3.8
31
102
28
1.0
n/a
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
TREND:
Improve/Worsening/Stable:
Arterial Blood Gas:
pH (7.35–7.45)
pCO2 (35–45)
pO2 (80–100)
HCO3 (18–26)
O2 sat (>92%)
Current:
7.25
68
52
36
84%
High/Low/WNL?
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
Urine Analysis (UA):
Color (yellow)
Clarity (clear)
Specific Gravity (1.015–1.030)
Protein (neg)
Glucose (neg)
Ketones (neg)
Bilirubin (neg)
Blood (neg)
Nitrite (neg)
LET (Leukocyte Esterase) (neg)
MICRO
RBCs (>> COPD/asthma
2. Albuterol (Ventolin) MDI 2 puffs every 4 hours prn>>> COPD/asthma
3. Lisinopril (Prinivil) 10 mg PO daily>>>hypertension
4. Gemfribrozil (Lopid) 600 mg PO bid>>>hyperlipidemia
5. Diazepam (Valium) 2.5 mg PO every 6 hours as needed>>>anxiety
6. Triamterene-HCTZ (Dyazide) 1 tab PO daily>>>hypertension
One disease process often influences the development of other illnesses. Based on your knowledge of
pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in her life?
Circle what PMH problem likely started FIRST
o 1 ppd smoker x40 years; quit 10 years ago
This is what caused the COPD domino to fall and is responsible for the respiratory complications
in her history.
Underline what PMH problem(s) FOLLOWED as domino(s)
o COPD/asthma
o Cor-pulmonale
Is right-sided hypertrophy of the heart caused by pulmonary hypertension that can lead to right
ventricular heart failure. It is a result of the increased resistance the right ventricle needs to
overcome to circulate blood into the lungs.
o Hypertension
Though cardiovascular in origin, smoking is also known to contribute to this problem. Nicotine is
a very potent vasoconstrictor!
o
Hyperlipidemia
© 2016 Keith Rischer/www.KeithRN.com
Smoking contributes to this problem because it lowers the HDL or “good cholesterol,” causing a
resultant increase in the LDL or “bad cholesterol.”
Patient Care Begins:
Current VS:
T: 103.2 F/39.6 C (oral)
P: 110 (regular)
R: 30 (labored)
BP: 178/96
O2 sat: 86% 6 liters n/c
P-Q-R-S-T Pain Assessment:
Provoking/Palliative: Deep breath/Shallow breathing
Ache
Quality:
Generalized over right side of chest with no radiation
Region/Radiation:
3/10
Severity:
Intermittent–lasting a few seconds
Timing:
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
T: 103.2 F/39.6 C (oral)
P: 110 (regular)
R: 30 (labored)
BP: 178/96
O2 sat: 86%
6 liters n/c
Temp has trended upward from her last reading at home. This reflects the body’s effort to
increase WBC/neutrophil production to fight sepsis and is a clinical RED FLAG.
Likely represents increased metabolism from respiratory distress, anxiety, and elevated
temperature.
Elevated due to underlying hypoxia from infection/pneumonia and difficulty to diffuse
O2/CO2 at the alveolar level as well as elevated temperature increasing metabolism.
With an infection of any kind, sepsis is identified by having two or more of the following
criteria of Systemic Inflammatory Response Syndrome (SIRS):
• Temp >100.4 or 90
• RR >20
• WBC >12,000 or 10%
All three of these vital sign components (temp/HR/RR) meet systemic inflammatory
response syndrome (SIRS) criteria. This patient could be septic, and is at risk for
progression to septic shock. This must be recognized by the nurse and is another clinical
RED FLAG.
Elevated due to anxiety and respiratory distress. Expected, but needs to be TRENDED over
time.
Elevated due to underlying hypoxia from infection/pneumonia and difficulty to diffuse
O2/CO2 at the alveolar level. This is the maximum amount of liter flow for nasal cannula
and therefore the nurse MUST use another method of delivering oxygen and assess response.
This could be a high flow n/c or face mask. Though this patient has COPD, she is also
hypoxic. Do not hesitate to administer enough oxygen to ensure adequate oxygenation. Most
people’s drive to breathe is based on CO2 in the blood, whereas those with COPD the drive
to breathe is based on hypoxemia. It’s very important to understand this because if the O2
level goes up too high, you may knock out their drive to breathe. It is common practice not
to give patients with COPD more than 2-3 liters of oxygen. On the other hand, oxygen
should never be withheld from a patient just because they have COPD. Closely assess
respiratory rate for a decrease to determine if the drive to breathe is impacted.
Words: Ache
Pain of any kind is RELEVANT and must be noted, by using PQRST or other
systematic pain assessment tools.
Intensity: 3/10
Location: Generalized
over right side of chest
with no radiation
This level of pain is low but needs to be trended closely.
Chest pain of any kind is ALWAYS a clinical RED FLAG and must be systematically assessed
to determine if it is cardiac. In hospitals that have a rapid response team, any chest pain
typically requires their assessment and a 12-lead EKG. BUT there are some simple
assessments that can be instituted by any nurse, to think critically and make a clinical
judgment if this pain is likely cardiac vs. non-cardiac in nature.
By situating your knowledge of what is expected with cardiac chest pain, pain that lasts only
a few seconds at a time does not fit a cardiac etiology. Anginal chest pain lasts minutes, NOT
Duration: Intermittent–
lasting a few seconds
© 2016 Keith Rischer/www.KeithRN.com
Aggreviate: Deep breath
Alleviate:Shallow
breathing
seconds.
This clinical data clearly supports a respiratory origin or pleuritic chest pain. Cardiac chest
pain is not typically influenced by deep breaths or relieved with shallow breathing. If a rapid
response team (RRT) was activated, this clinical data will help guide clinical decisionmaking. A 12-lead EKG is standard with any complaint of chest pain and will help to
conclusively rule out a cardiac origin of this pain. New T-wave inversion or ST segment
elevation or depression are changes that an experienced nurse must assess. EKGs must be
interpreted by a provider ASAP.
Current Assessment:
GENERAL
APPEARANCE:
RESP:
CARDIAC:
NEURO:
GI:
GU:
SKIN:
Appears anxious and in distress, barrel chest present
Dyspnea with use of accessory muscles, breath sounds very diminished bilaterally ant/post
with scattered expiratory wheezing
Pale, hot & dry, no edema, heart sounds regular–S1S2, pulses strong, equal with palpation at
radial/pedal/post-tibial landmarks
Alert & oriented to person, place, time, and situation (x4)
Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants
Voiding without difficulty, urine clear/yellow
Skin integrity intact, skin turgor elastic, no tenting present
What assessment data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data:
Clinical Significance:
GENERAL APPEARANCE:
Knowing that she has an anxiety history, the nurse must be able to cluster
Appears anxious and in distress, barrel
relevant vital signs and assessment data to determine if there is a
chest present
physiologic basis for her anxiety. Because hypoxia is present, her anxiety is
present because of her respiratory distress. It may be exacerbated by her
anxiety disorder. You must utilize the “art” of nursing to demonstrate care
and support to try to decrease anxiety that will work against you in the
context of respiratory distress. Not all patients with COPD have a barrel
chest. This finding is found in those with progression of the severity of
COPD which is relevant clinical data to the nurse.
RESP: Dyspnea with use of accessory
muscles, breath sounds very diminished
bilaterally with scattered expiratory
wheezing
Retractions must be recognized as a clinical RED FLAG! Why are they
present? In respiratory distress, the skeletal muscles are used to improve
ventilation.
Diminished aeration could be her baseline due to COPD, but must be noted.
Wheezing represents narrowed bronchioles that are whistling. Expiratory
wheezing is more common and typically indicates less severe broncho
constriction. Inspiratory wheezing with expiratory wheezing can represent
more severe narrowing and must be recognized as a clinical RED FLAG.
CARDIAC: Pale, hot & dry
This data confirms the presence of a fever. Her paleness could be due to
sympathetic nervous system stimulation (fight or flight) and is expected in
this context.
GU: Voiding without difficulty, urine
clear/yellow
Though these are normal findings, this is an excellent example of the
importance of the nurse’s recognizing RELEVANT NORMAL findings.
Because Joan is an elderly woman with a likely infection, the presence of a
urinary tract infection (UTI) must also be considered. There is no painful
burning or frequency of urination, so this is likely not a contributing
problem to her respiratory infection.
© 2016 Keith Rischer/www.KeithRN.com
12 Lead EKG
Interpretation:
Sinus tachycardia
Clinical Significance:
There are no ST segment or T-wave changes that represent acute ischemia. P-waves representing sinus activity are
clearly present. Nothing is suggestive of acute coronary syndrome.
Chest x-ray:
What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Results: Clinical Significance:
Left lower lobe infiltrate. Infiltrate reflects the consolidation and presence of exudates/secretions caused by the
Hypoventilation present
infection/inflammatory process seen in pneumonia. The hypoventilation is an expected
in both lung fields
finding in end-stage COPD.
Lab Results:
What lab results are RELEVANT that must be recognized as clinically significant to the nurse?
Complete Blood Count (CBC)
WBC (4.5–11.0 mm 3)
Hgb (12–16 g/dL)
Platelets (150–450x 103/µl)
Neutrophil % (42–72)
Band forms (3–5%)
Current:
14.5
13.3
217
92
5
High/Low/WNL?
HIGH
WNL
WNL
HIGH
WNL barely!
Previous:
8.2
12.8
298
75
1
What lab results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Lab(s):
Clinical Significance:
TREND: Improve/Worsening/Stable:
WBC: 14.5
Body is mounting immune response to
underlying infection. WBC elevation is due
primarily to the increased production of
neutrophils, which are the “first responders”
of the immune system.
Worsening
Neutrophil: 92%
The elevation of neutrophils in response to a
bacterial infection begins as early as 6 hours
Worsening…LEFT SHIFT…a clinical RED
FLAG
© 2016 Keith Rischer/www.KeithRN.com
after the initial insult. This percentage of
elevation with the increase in overall WBC
reveals that the body is responding to a
significant invasion of bacteria and may
have gone systemic! Though >80 percent
neutrophil elevation is a clinical RED FLAG,
90 percent is especially concerning. In the
chart, health-care providers will refer to this
significant elevation as a “left shift.”
Band forms: 5%
Bands are immature neutrophils that are
present when the body is overwhelmed by
bacterial organisms and are needed to fight.
It releases these immature WBCs from the
bone marrow into circulation.
Basic Metabolic Panel (BMP:)
Sodium (135–145 mEq/L)
Potassium (3.5–5.0 mEq/L)
CO2 (Bicarb) (21–31 mmol/L)
Glucose (70–110 mg/dL)
BUN (7–25 mg/dl)
Creatinine (0.6–1.2 mg/dL)
Misc. Labs:
Lactate (0.5–2.2 mmol/L)
Worsening… Although a lab may be within
range, values on the high range of normal
can be clinically significant and need to be
TRENDED. The nurse must not look at any
lab and assume that because it is “normal” it
is not relevant and can be ignored.
Current:
138
3.9
35
112
32
1.2
High/Low/WNL?
WNL
WNL
HIGH
HIGH-barely
HIGH
WNL
Previous:
142
3.8
31
102
28
1.0
3.2
HIGH
n/a
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
TREND:
Improve/Worsening/Stable:
Though sodium,
potassium, and creatinine
are ALWAYS relevant, in
this scenario, the
following labs must also
be noted!
CO2: 35
Though not typically relevant, WHY is this lab
elevated?
In a patient with chronic COPD, the clinical
RELATIONSHIP of CO2 retention requiring
metabolic compensation must be recognized.
This same dynamic is also commonly seen on an
ABG as well. CO2 is a BASE in a BMP.
Worsening slightly
Glucose: 112
Though she is not diabetic, clinical reasoning
requires the nurse to TREND all relevant data.
In this scenario, she has been on prednisone
and has just received hydrocortisone IV, these
medications will elevate blood glucose. This
must be noted.
Worsening slightly but not clinically
significant especially in the context of
physiologic stress where cortisol will be
increased and with it higher blood
glucose levels
BUN: 35
The RELATIONSHIP of an elevated BUN and a
borderline high creatinine must be recognized
Worsening slightly
© 2016 Keith Rischer/www.KeithRN.com
because they both represent renal function,
though BUN is more indirect than creatinine.
Creatinine: 1.2
Though creatinine is ALWAYS relevant, the
nurse must note is that though this value is
WNL, it is on the HIGH end of normal, and is
TRENDING higher than the most recent. This
may be significant, so it requires the nurse to
closely TREND as well as closely assess renal
function, I&Os and urine output.
Worsening slightly. Because creatinine is
a more direct reflector of renal function,
this must be assessed closely.
Lactate: 3.2
This is the most concerning finding that must be
assessed and trended carefully because its
elevation confirms the possibility of SEPSIS, a
systemic infection that can be transported
through the blood to the entire body. Lactate
elevation reflects anaerobic metabolism that is
found as sepsis progresses to septic shock due
to poor perfusion.
Fever tachycardia with hypotension will be
affected, and each of these must be TRENDED
as sepsis progresses. This is the most accurate
means to assess and determine current clinical
status and what direction this patient will go.
Remember CO=SVxHR? This formula becomes
very RELEVANT if sepsis progresses to septic
shock because tachycardia will be present with
a normal BP in EARLY shock of any kind. In
order to rescue this patient or any other patient,
TACHYCARDIA WITH NO APPARENT
ETIOLOGY IS ALWAYS A CLINICAL RED
FLAG. It is there for a reason!
No prior level, but in this scenario it does
not matter!
Any lactate >2 is a RED FLAG that must
be recognized by the nurse.
Arterial Blood Gas:
pH (7.35–7.45)
pCO2 (35–45)
pO2 (80–100)
HCO3 (18–26)
O2 sat (>92%)
Current:
7.25
68
52
36
84%
High/Low/WNL?
LOW
HIGH
LOW
HIGH
LOW
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
pH: 7.25
Acidosis. This is the first step to interpreting this ABG. The next step is to determine if it is
metabolic or respiratory driven. Need to take a look at the pCO2 next.
pCO2: 68
This is significantly higher than what you would expect with a COPD patient with CO2
retention as a baseline. The acidosis is respiratory in origin because the HCO3 is elevated.
Next need to see how she is oxygenating to see if there is a problem.
pO2: 52
There is a problem and a clinical RED FLAG! This is much lower than expected and
represents significant hypoxia.
HCO3: 36
This bicarbonate level is expected because it correlates closely to the CO2 level (bicarb) on
the BMP. Why is it elevated? COPD with CO2 retention makes it evident that this is a long-
© 2016 Keith Rischer/www.KeithRN.com
term compensatory response that the body has adjusted to maintain normal pH.
O2 sat: 84%
The RELATIONSHIP of the pO2 of 52 and this low saturation must be recognized by the
nurse. This low sat is expected, but confirms the severity of Joan’s inability to ventilate
adequately. She may be close to requiring bipap or even emergent intubation if this does not
turn around soon!
ABG Interpretation:
RESPIRATORY ACIDOSIS–NON-COMPENSATED
Low pO2 reflects inability to diffuse O2 across the alveoli, and correlates with 84 percent
saturation. With any patient who has COPD in respiratory distress, NEVER fail to
aggressively titrate O2 to improve oxygenation. Rarely will you affect the respiratory drive,
and you can deal with that if it develops. Give Joan what she clearly needs, which is as much
O2 as needed to relieve her hypoxia. In my 30+ years of clinical practice, I have not seen a
COPD patient stop breathing because they received too much oxygen. Experienced
respiratory therapists have also confirmed that this is rarely seen clinically–but it is
theoretically possible and mentioned in most nursing textbooks.
Urine Analysis (UA):
Color (yellow)
Clarity (clear)
Specific Gravity (1.015–1.030)
Protein (neg)
Glucose (neg)
Ketones (neg)
Bilirubin (neg)
Blood (neg)
Nitrite (neg)
LET (Leukocyte Esterase) (neg)
MICRO
RBCs (2.0
reflects anaerobic
metabolism that is
Critical Value: found as sepsis
progresses to septic
>5.0
shock due to poor
perfusion.
Nursing Assessments/Interventions Required:
*Assess closely for tachycardia as well as hypotension with
known infection (septic shock).
*Monitor blood pressure and heart rate closely for
concerning trends of increasing HR, and decreasing BP.
Remember importance of trending all vital sign data and
assessing direction these trends are going.
*Assess closely for any change in temperature–hypothermia
or febrile can both represent sepsis, especially in elderly
patients.
Clinical Reasoning Begins…
1. What is the primary problem that your patient is most likely presenting with?
Acute COPD exacerbation most likely caused by pneumonia
2. What is the underlying cause/pathophysiology of this primary problem?
COPD
o The chronic obstructive lung diseases include emphysema, chronic obstructive bronchitis, chronic
bronchitis, and asthmatic bronchitis.
o These respiratory illnesses share the common pathology of increased resistance to air movement,
prolongation of the expiratory phase of respiration, and loss of the normal elasticity of the lung.
o Most patients with chronic airflow limitations are or were smokers, and their lung disease is a direct
consequence of the toxic effects of tobacco smoke on the lung (Venes, 2013).
Pneumonia
o Is an inflammatory condition of the interstitial lung tissue. Fluid and blood cells escape into the alveoli.
The disease process begins with an infection in the alveolar spaces. As the organism multiplies, the
alveolar spaces fill with fluid, white blood cells, and cellular debris from phagocytosis of the infectious
agent. The infection spreads from the alveolus and can involve the distal airways (bronchopneumonia),
part of a lobe (lobular pneumonia), or an entire lung (lobar pneumonia).
o The inflammatory process causes the lung tissue to stiffen, resulting in a decrease in lung compliance and
increase in the work of breathing. The fluid-filled alveoli cause a physiological shunt, and venous blood
passes unventilated portions of lung tissue and returns to the left atrium unoxygenated. As the arterial
oxygen tension falls, the patient begins to exhibit the signs and symptoms of hypoxemia. In addition to
hypoxemia, pneumonia can lead to respiratory failure and septic shock. (Sommers & Fannin, 2015).
© 2016 Keith Rischer/www.KeithRN.com
Collaborative Care: Medical Management
Care Provider Orders:
Albuterol-ipratropium 2.5
mg neb
Rationale:
Albuterol–-short-acting bronchodilator to open
bronchioles and improve oxygenation. Binds to beta 2
receptors on smooth muscles of the airway causing
bronchodilation.
Ipratropium: MAST CELL STABILIZER–maintains
bronchodilation and minimizes inflammation response
and related histamine release.
Expected Outcome:
Improved oxygenation
Establish peripheral IV
Anticipate the need for IV antibiotics and ensure that
they are ordered and administered after blood cultures
have been drawn and IV fluids.
IV present and patent
Lorazepam 1 mg IV push
every 6 hours prn anxiety
Decreases anxiety and improves oxygenation. Depresses
the CNS
Decreased anxiety with
resultant improved oxygenation
possibly…
Methylprednisolone 125 mg
IV push
An injectable steroid, it will suppress inflammation that
is primarily present in the lungs/bronchioles, which is
desirable to improve oxygenation, but is NOT immediate
in its effect. Has an undesirable effect, which is the
suppression of the immune system in this context.
Improved oxygenation, but
NOT right away
Levofloxacin 750 mg IVPB
(after blood cultures drawn)
Inhibits DNA gyrase (bacterial topoisomerase II), an
enzyme required for DNA replication, transcription,
repair, and recombination, which will prevent bacterial
growth.
Improved oxygenation as
pneumonia improves. Typically
after 24-48 hours
Acetaminophen 1000mg oral
Though a fever is beneficial, the severity and the ability
to physiologically tolerate the increased metabolic
demands on the body (increased RR, HR) will dictate if
you need to treat this fever.
Lower body temperature
PRIORITY Setting: Which Orders Do You Implement First and Why?
Care Provider Orders:
1. Albuterol-ipratropium 2.5
mg neb
2. Establish peripheral IV
3. Lorazepam 1 mg IV push
4. Methylprednisolone 125
mg IV push
5. Levofloxacin 750 mg
IVPB (after blood cultures
drawn)
6. Acetaminophen 1000mg
PO
Order of Priority:
1. Albuterol-ipratropium 2.5
mg neb
2. Establish peripheral IV
3. Lorazepam 1 mg IV push
4. Levofloxacin 750 mg
IVPB (after blood cultures
drawn)
5. Methylprednisolone 125
mg IV push
6. Acetaminophen 1000mg
PO
© 2016 Keith Rischer/www.KeithRN.com
Rationale:
This is an excellent example of the relevance of the A, B, Cs
to setting priorities in practice. The nurse must be able to
recognize and identify which interventions impact A, B or
C. This is why the nurse must also understand the
physician’s plan of care and interventions!
1. A/B airway/breathing: will open airways
2. C-circulation: establish IV to administer needed IV meds
3. Not a direct B priority, but will actually help improve
oxygenation once IV is established
4. Will take 24-48 hours to impact pneumonia but need to
start ASAP!
5. Will not work as quickly as albuterol to open airways by
decreasing bronchial swelling
6. Fever control needed, but other medical interventions
are high priority
Collaborative Care: Nursing
3. What nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY)
Though NANDA nursing diagnostic statements do not always capture the essence, urgency, and priority of a patient
in crisis, in this scenario, the following statements do apply and are relevant:
IMPAIRED GAS EXCHANGE
INEFFECTIVE AIRWAY CLEARANCE
ALTERED BODY TEMPERATURE
ANXIETY
4. What interventions will you initiate based on this priority?
Nursing Interventions:
Rationale:
IMPAIRED GAS EXCHANGE r/t lung
consolidation with decrease in surface area
available for gas exchange
1. Auscultate breath sounds every1-2
hours and PRN if status changes
2. Continuous pulse oximeter
3. Supplemental O2 to keep sat >90
percent
4. Assess respiratory pattern noting rate,
depth, and effort
5. Place in high semi Fowlers position
6. Monitor for behavior or mental status
changes
INEFFECTIVE AIRWAY
CLEARANCE…r/t retained tracheobronchial
secretions secondary to inflammation process
1. Assess secretions, noting color,
consistency, and amount
2. Encourage incentive spirometer every 1
hour while awake
1. Establish baseline and note any TREND
that indicates worsening status
2. Establish TREND and note any
deterioration sooner vs. later! Remember to
validate reading with correlating HR on
pulse oximeter.
3. Patient will need higher concentration of
O2 in the acute phase to maintain adequate
oxygenation
4. Note any TREND that indicates worsening
status.
5. Easier to ventilate and oxygenate sitting up.
6. Change in mentation/decreased level of
consciousness (LOC) is early sign of
deterioration with a gas exchange problem.
Usually hypercarbia or retaining CO2.
Expected Outcome:
1. No change in
adventitious breath
sounds
2. Sat maintain >90%
3. n/a
4. No pattern of
distress
5. Oxygenation
improved
6. No changes in LOC
or mental status
1. Note any TREND that indicates worsening
status–amount or change in color
2. Promotes alveolar expansion, which will
promote oxygenation
3. Will help to liquefy secretions and make
them easier to expectorate. Assess closely for
volume overload because of history of cor
pulmonale or right-sided heart failure
1. Secretions do not
have color to them or
decrease in
frequency
2. Oxygenation/O2 sat
improves
3. Phlegm not as thick
1. Elevated temp is early response to
inflammation/infectious presence. Chills
represent rapidly rising temperature.
2. Promotes comfort by lowering body
temperature closer to normal limits.
3. In this context, fluids are needed to replace
insensible fluid loss due to fever.
4. Allow heat to be removed.
1. Temp remains WNL
3. Encourage fluids, but assess closely for
volume overload
ALTERED BODY TEMPERATURE r/t
infectious process
1. Assess temp every 4 hours–-assess for
presence of chills
2. Administer acetaminophen prn
3. Encourage oral fluids
4. Remove/adjust clothing/blankets
2. Temp decreased
3. Tolerates fluids
4. Temperature remains
within normal range
5. What body system(s) will you most thoroughly assess based on the primary/priority concern?
Respiratory
© 2016 Keith Rischer/www.KeithRN.com
o
Recognize the clinical RELATIONSHIP of impaired ventilation and neurologic status. As CO2 levels rise,
mentation goes from increased confusion/agitation to decreased level of consciousness, which would
likely require intubation. We are not there yet, but this correlation needs to be on the radar screen of the
nurse as part of ongoing assessment priorities.
Cardiac
o The potential for sepsis/septic shock must be anticipated by the nurse with any severe infectious process
in a susceptible host. Therefore close assessment of the CV system is a must. This would include close
TRENDING of heart rate that could elevate, and BP that TRENDS downward over time. In addition to
the presence of diaphoresis, pale, cool skin, or decreased pulses must also be assessed closely as well.
6. What is the worst possible/most likely complication to anticipate?
o Respiratory failure resulting in decreased oxygenation that does not respond to increasing O2 amounts.
This would require either Bipap or intubation.
o
Sepsis/septic shock
7. What nursing assessments will identify this complication EARLY if it develops?
Respiratory failure
o O2 sat that continues to decrease despite placing on bipap and maximizing settings and delivery of O2max of 100 percent.
o Assess current ABGs to assess acid-base imbalance and current pCO2 and pO2
o Increased RR and work of breathing with use of accessory muscles
o Level of consciousness (LOC)–increased lethargy or unresponsiveness–ominous sign that usually reflects
increased CO2 levels
Sepsis/septic shock
o TRENDING of heart rate that would increase, and BP that TRENDS downward over time. In addition,
the presence of diaphoresis, pale, cool skin, or decreased pulses must also be assessed closely as well.
o With an infection of any kind, sepsis is identified by having two or more of the following criteria of
Systemic Inflammatory Response Syndrome (SIRS):
Temp >100.4 or 90
RR >20
WBC >12,000 or 10%
8. What nursing interventions will you initiate if this complication develops?
Respiratory failure
o Contact respiratory therapy stat to place on bipap
o Call a code if continues to decompensate to facilitate needed intubation
Sepsis/septic shock
o Call “Rapid Response” if team available in facility
o Establish second IV, preferably a large bore IV (18 g).
o Obtain VS every 15 minutes to TREND closely.
o Contact primary care provider as soon as change in status is identified as well as need to transfer to ICU.
o Initiate IV bolus of at least 1-2 liters of isotonic solution such as 0.9 percent NS per rapid response
protocol or physician orders
o Anticipate need to start IV continuous vasopressors such as norepinephrine or neosynephrine.
9. What psychosocial needs will this patient and/or family likely have that will need to be addressed?
Knowledge and education about what is taking place and the care priorities for the days ahead
Emotional support
Spiritual support
© 2016 Keith Rischer/www.KeithRN.com
10. How can the nurse address these psychosocial needs?
Knowledge and education regarding illness and plan of care
o The nurse can integrate patient/family education naturally while providing care by simply explaining at
their level everything that the nurse/physician has ordered and WHY it needs to be done. This is why it is
essential for the nurse to know and DEEPLY understand the rationale for both the physician and nursing
plan of care.
Emotional support
o BE PRESENT and AVAILABLE. See the section on caring at the end of this case study for more
information.
Spiritual support
o In the ED, spiritual care/support will be limited to encouragement, providing hope, and determining if the
patient would like to have a chaplain or their spiritual leader notified.
o Once admitted, it would be appropriate to ask open-ended questions to assess. Those that I have found
natural and effective include:
What gives your life purpose?
How has this illness affected the way you view life?
What is the source of your strength to face the future?
Are you involved/connected with a faith community?
If answers yes to above question…How has your current health problem affected your spiritual;
beliefs?
Medication Dosage Calculation:
Medication/Dose:
Mechanism of Action:
Lorazepam
Exerts tranquilizing
action on the central
nervous system with no
appreciable effect on the
respiratory or
cardiovascular system
1 mg IV push
(2 mg/1 mL vial)
Volume/time frame to
Safely Administer:
Nursing Assessment/Considerations:
0.5 mL lorazepam
*Assess closely for dizziness, drowsiness.
* CNS side effects increase with the
elderly.
(Vallerand, Sanoski, & Deglin, 2014).
(Davis Drug states that
should be diluted with
equal amount of sterile
water, or 0.9 percent NS
for injection).
THEREFORE:
Total volume 1.0 mL
IV Push:
Volume every 15 sec?
Davis Drug: rate not to
exceed 2 mg/minute
THEREFORE this dose
could be given over 30
seconds in 0.5 mL
increments every 15
seconds
Medication/Dose:
Mechanism of Action:
Volume/time frame to
Safely Administer:
Methylprednisolone
An injectable steroid, it will
suppress inflammation that
is primarily present in the
lungs/bronchioles, which is
desirable, but also has an
undesirable effect, which is
the suppression of the
2 mL
125 mg IV push
(125 mg/2 mL vial)
© 2016 Keith Rischer/www.KeithRN.com
IV Push:
Volume every 15 sec?
Davis Drug: 1-2
minutes THEREFORE
if you choose over 2
Nursing
Assessment/Considerations:
*Causes hyperglycemia–monitor
glucose levels closely, especially if
patient is diabetic
*Blunts immune response and WBC
count–assess closely for signs of
infection or worsening status
*Decreases serum K+ levels and
immune system.
minutes will be 0.25mL
increments every 15
seconds
Medication/Dose:
Mechanism of Action:
Volume/time frame to
Safely Administer:
levofloxacin
Inhibits DNA gyrase
(bacterial topoisomerase
II), an enzyme required
for DNA replication,
transcription, repair, and
recombination
150 mL over 90
minutes
750 mg IVPB
(150 mL volume)
Hourly rate IVPB:
225 mL/hour
increases Na+. Monitor these labs
closely
*Assess for signs of adrenal
insufficiency that can cause
hypotension, weight loss, weakness,
N&V, confusion, peripheral edema
*Monitor I&O and daily weights for
signs of adrenal insufficiency
(Vallerand, Sanoski, & Deglin,
2014).
Nursing Assessment/Considerations:
*Obtain any specimen cultures before
giving first dose
*Assess for allergic response of any kind
(rash-itching-hives-anaphylacticrespiratory distress)
*Continue to assess for response to
infection and evaluate response
(Vallerand, Sanoski, & Deglin, 2014).
Evaluation:
One hour later…
You have been able to implement all orders and it has been 30 minutes since the last nebulizer treatment. Your collect
the following clinical reassessment data:
Current VS:
T: 100.8 F/38.2 C (oral)
P: 88 (regular)
R: 24 (slight labored)
BP: 128/90
O2 sat: 92% 4 liters n/c
Current
Assessment:
GENERAL
APPEARANCE:
RESP:
CARDIAC:
NEURO:
GI:
GU:
SKIN:
Most Recent:
T: 103.2 F/39.6 C (oral)
P: 110 (regular)
R: 30 (labored)
BP: 178/96
O2 sat: 86% 6 liters n/c
Current PQRST:
Provoking/Palliative:
Quality:
Region/Radiation:
Severity:
Timing:
Denies pain
Resting quietly, appears in no acute distress
Breath sounds improved aeration bilaterally, coarse crackles with diminished aeration in left
lower lobe (LLL)
Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal
with palpation at radial/pedal/post-tibial landmarks
Alert & oriented to person, place, time, and situation (x4)
Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants
Voiding without difficulty, urine clear/yellow
Skin integrity intact
1. What clinical data are RELEVANT that must be recognized as clinically significant?
RELEVANT VS Data:
Clinical Significance:
In this reassessment, ALL vital sign data are relevant and must be noted.
Emphasize the TREND of each of these findings and determine if Joan is
improving or not, based on not only the current findings, but also the
© 2016 Keith Rischer/www.KeithRN.com
direction of each of these clinical TRENDS. This is the essence of
CLINICAL REASONING and why it must be emphasized to prepare every
student for clinical practice!
T: 100.8 F/38.2 C (oral)
Trending DOWN. Though elevated, the acetaminophen has helped to bring
temperature down.
P: 88 (regular)
Trending DOWN. Though WNL, when compared to most recent, it reflects a
decreased temperature, less anxiety, and less sympathetic nervous system
activity.
R: 24 (slight labored)
Trending DOWN. Though elevated, it is coming down. This data must be
clustered with O2 sat to thoroughly assess improvement in oxygenation.
BP: 128/90
Trending DOWN. Though essentially WNL, it reflects less anxiety and less
sympathetic nervous system activity. Though sepsis was a possible concern,
because the BP is WNL, and the HR has DECREASED, not increased,
progression of sepsis is not present at this time.
O2 sat: 92% 4 liters n/c
Trending UP. This clinical data of improving O2 sat with LESS O2 is clearly
representing improved ventilation.
RELEVANT Assessment Data:
GENERAL APPEARANCE: Resting
quietly, appears in no acute distress
Clinical Significance:
RESP: Breath sounds improved aeration
bilaterally, coarse crackles with
diminished aeration in left lower lobe
(LLL)
When clustered with O2 sat and RR, clearly reveals that she is improving
her ventilation and oxygenation.
The clinical RELATIONSHIP of the known infiltrate in the LLL and
diminished aeration and coarse crackles in LLL must be recognized. Though
abnormal, this is EXPECTED because the infiltrate and secretions from
infection in bronchioles will cause both of these assessment findings in this
location.
If Joan was hypoxic and in distress with sympathetic nervous system
stimulation, she would not be exhibiting this! Her appearance is clearly
suggesting clinical improvement! Another thing that the nurse must consider
is that “resting quietly” can be present with altered mental status that can
be seen with elevated CO2 levels so make sure that students understand that
“quiet, resting” patients does not always mean that everything is ok.
You report your assessment findings to the primary care provider who decides to repeat the ABG. You obtain
the following results:
Arterial Blood Gas:
pH (7.35–7.45)
pCO2 (35–45)
pO2 (8–-100)
HCO3 (18–26)
O2 sat (>92%)
Current:
7.31
55
78
35
91%
Most Recent:
7.25
68
52
36
84%
1. Has the status improved or not as expected to this point?
Yes, it has. All of the clinical data (vital signs and assessment) discussed above clearly represent improved ventilation and
oxygenation.
This most recent ABG confirms what we already know! Now interpret this ABG, clinically reason, and take a closer look
at the TRENDS in this ABG to determine the significance of these most recent findings.
Interpretation: RESPIRATORY ACIDOSIS still partial compensation (pH is NOT WNL yet))
pH: 7.31
o Trending UP. The question is why? Take a look at pCO2.
© 2016 Keith Rischer/www.KeithRN.com
pCO2: 55
o Trending DOWN. A good thing. Shows improved ventilation and is responsible for increasing pH.
pO2: 78
o Trending UP. Also a good thing Also reflects improved ventilation/oxygenation.
HCO3: 35
o Trending same. This is expected, as any acidotic state will not be reflected metabolically within 24 hours.
O2 sat: 91%
o Trending UP. Another good sign of improved ventilation/oxygenation.
2. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
Though improving clinically, the nursing priorities that we identified at the beginning are all still relevant. Joan is not yet
out of the woods, but requires vigilant assessment to make sure that the progress she has made does not change
over time. Emphasize to students that with any new admission, the first 24 hours are the most crucial. this is when
you will likely see changes that will require the nurse to RESCUE due to a change in status.
3. Based on your current evaluation, what are your nursing priorities and plan of care?
See above. But from what was identified at the onset of Joan’s admission, this is the most relevant:
IMPAIRED GAS EXCHANGE
1. Auscultate breath sounds every 1–2 hours
2. Continuous oximeter
3. Supplemental O2 to keep sat >90%
4. Assess respiratory pattern noting quality, rate, presence of retractions
5. Place in high semi fowlers position
It is has been two hours since Joan arrived in the ED. It is now time to transfer your patient to the floor. Effective and
concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You
have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be
caring for this patient:
Situation:
Name/age:
Joan Walker is a 84-year-old woman
BRIEF summary of primary problem:
She has had a productive cough of green phlegm four days ago that persists. She was started three days ago on
prednisone 60 mg PO daily and azithromycin (Zithromax) 250 mg PO x5 days by her clinic physician. Though she has
had intermittent chills, she first noticed a fever last night of 102.0 F/38.9 C. She has had more difficulty breathing
during the night and has been using her albuterol inhaler every 1–2 hours with no improvement. Transported to ED by
EMS.
Day of admission/post-op #:
Day of admission
Background:
Primary problem/diagnosis:
Pneumonia/COPD exacerbation
RELEVANT past medical history:
COPD/asthma
Cor-pulmonale
© 2016 Keith Rischer/www.KeithRN.com
Anxiety
1 ppd smoker x40 years; quit 10 years ago
Assessment:
Vital signs:
T: 100.8 F/38.2 C (oral)
P: 88 (regular)
R: 24 (slight labored)
BP: 128/90
O2 sat: 92%
4 liters n/c
RELEVANT body system nursing assessment data:
Pain 3/10 pleuritic chest pain that increases with deep breath. 12-lead EKG sinus tachycardia with no ST/T wave
changes
Initial Assessment:
GENERAL APPEARANCE: Appears anxious and in distress
RESP: Dyspnea with intercostal retractions, breath sounds very diminished bilaterally with scattered expiratory
wheezing
Received in the last hour:
lorazepam 1 mg IV push
methylprednisolone 125 mg IV push
levofloxacin 750 mg IVPB
acetaminophen 1000mg PO
Current Assessment:
GENERAL APPEARANCE: Resting comfortably, appears in no acute distress
RESP: Breath sounds improved aeration bilaterally, coarse crackles with diminished aeration in left lower lobe (LLL)
RELEVANT lab values:
CXR: Left lower lobe infiltrate. Hypoventilation present in both lung fields
Lactate: 3.2
WBC: 14.5
Neutrophil: 92%
Arterial Blood Gas:
pH: 7.31
pCO2: 55
pO2: 78
HCO3: 35
O2 sat: 91%
TREND of any abnormal clinical data (stable-increasing/decreasing):
ABGs improving
INTERPRETATION of current clinical status (stable/unstable/worsening):
Stable but requires close monitoring
Recommendation:
Suggestions to advance plan of care:
Transfer to floor. Continue to assess respiratory status closely!
Education Priorities/Discharge Planning
© 2016 Keith Rischer/www.KeithRN.com
1. What will be the most important discharge/education priorities you will reinforce with her medical condition to
prevent future readmission with the same problem?
Though discharge education is not a high priority this early in an admission, the nurse must plan and prepare for the
highest educational priorities and incorporate them during the shift of care. Never assume that the patient has
knowledge of needed educational priorities with chronic medical conditions. The following must be reviewed:
Ensure that she is up to date on immunizations, including pneumococcal pneumonia and influenza.
Pursed lip breathing
Signs of COPD exacerbation and when she should come to the ED for evaluation
Review action/indications for use of all relevant medications, especially her inhalers. Which inhaler should
she use first? (bronchodilator)
Proper use of spacers or other devices to optimize inhalation of metered dose inhalers (MDI) in the lungs
Decreased endurance–how she can conserve energy.
Consider occupational therapy (OT) referral
2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?
After any education has been completed with the patient or family, one of the more effective strategies to assess
effectiveness of teaching is to have them restate the essence or most important points of your teaching = and repeat it
later in the shift to ensure retention. Have her demonstrate the use of an inhaler and rinse her mouth after use.
Caring and the “Art” of Nursing
1. What is the patient likely experiencing/feeling right now in this situation?
The nurse needs to put her/himself in the patient’s place to identify what is being experienced in this situation. The
patient is likely aware of the seriousness of the current change in status and is likely fearful and anxious. A practice of
intentionally supporting both the patient and family by giving them as much information about their current status
and explaining the plan of care from both a nursing and medical perspective is important. KNOWLEDGE is POWER
from a patient’s perspective, and when the nurse provides this information it will DECREASE anxiety and fear and
make a real difference in her well-being. Even in the context of a patient who is critically ill, when you simply and
matter-of-factly share what you are doing and why, it demonstrates the caring and support that is needed.
2. What can you do to engage yourself with this patient’s experience and show that she matters to you as a person?
Prayer and spirituality is important to Joan. The nurse can practically support Joan by acknowledging this and
offering to support her spiritually. If a patient communicates that they would like to involve the nurse in prayer, the
nurse has to make a decision about how to handle prayer. He/she can join in with the patient and pastor or stand
quietly while they pray. It can be very reassuring to patients to have a nurse join in prayer or pray with them. From a
patient’s perspective, when a nurse is willing to “go there”, it is something they will always remember because it so
clearly communicates caring!
If you pray with a patient, you must first be comfortable with prayer. If not, don’t do it. Secondly, get the
patient’s permission. The nurse should ask, “Would you like me to pray with you?” if you sense a need or the patient
appears to be open. If yes, then ask the patient, “How would you like me to pray for you?” Notice that all spiritual
care must be PATIENT-centered and NOT driven or dictated by the nurse. Remember, if you are not comfortable with
prayer, then get a consult for pastoral care to minister to the patient if the patient wants this. Spiritual care is
expected by the Joint Commission, who have mandated that a spiritual assessment and spiritual care is provided to
every patient who is admitted to the hospital!
Regardless of the clinical setting, remember the importance of touch and your presence as you provide care. If
you are using Swanson’s Caring framework (which I encourage you to do–see my “Teaching Caring” tab on
KeithRN.com), the following practical caring interventions can be “tools” in your caring toolbox to use depending on
the circumstance and the patient needs:
o
o
o
Comforting
Little things to comfort–whatever it may be–are needed and appreciated!
Anticipating their needs
Staying one step ahead and not behind, especially in a crisis is essential!
Performing competently/skillfully
Remember that when a nurse or student nurse does their job well and competently, this
demonstrates caring to the patient!
© 2016 Keith Rischer/www.KeithRN.com
o
o
Preserving dignity
Maintaining privacy at all times when in crisis and vulnerable is essential and is all too easily
forgotten due to pressing physical needs. Pulling the curtain is all that is as well as covering
exposed genitalia when are little things but so important to preserve human dignity.
Informing/explaining–patient education
Even in a crisis, simply explaing all that you are doing. If your patient is not able to respond but
if family are present, do not forget to explain all that you are doing and why. This is truly the
“art” of nursing and makes such a difference when done in practice!
Use Reflection to THINK Like a Nurse
Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention
in the moment as the events are unfolding to make a correct clinical judgment.
1. What did I learn from this scenario?
Have students share and reflect
2.
How can I use what has been learned from this scenario to improve patient care in the future?
Have students share and reflect
Author
Keith Rischer, RN, MA, CEN, CCRN
Reviewers
Charlotte Powell, MSN, RN, Assistant Professor, Black Hawk College, Moline, Illinois
Julie A. Hogue, RN, MSN, Nursing Instructor, Illinois Valley Community College, Oglesby, Illinois
Sarah R. Pierce, DNP, AGACNP-BC, CCRN, PLNC, Freed-Hardeman University, Henderson, Tennessee
References
Ackley, B. J. & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care. (10th ed.).
St. Louis, MO: Mosby Elsevier.
LeMone, P., Burke, K., Bauldoff, G., & Gubrud, P. (2015). Medical surgical nursing: Clinical reasoning in patient care.
(6th ed.). Hoboken, NJ: Pearson Education, Inc.
Rochester, C., Martinello, R., Sethi, S, & Thien, F. (2016). Acute COPD exacerbation. Retrieved from
www.epocrates.com
Sharifabad, M., Ashtyani, H., Janssen, W., & Thien, F. (2016). COPD. Retrieved from www.epocrates.com
Sommers, M.S. & Fannin, E. (2015). Diseases and disorders: A nursing therapeutic manual. (5th ed.). Philadelphia, PA:
F.A. Davis Company.
Swanson, K.M. (1991). Empirical development of a middle range theory of caring. Nursing Research, 40(3), 161–166.
Vallerand, A.H., Sanoski, C.A., & Deglin, J.H. (2014) Davis’s drug guide for nurses. (14th ed.). Philadelphia, PA: F.A.
Davis Company.
Van Leeuwen, A. & Bladh, M.L. (2015). Davis’s comprehensive handbook of laboratory and diagnostic tests with
nursing implications. (6th ed.). Philadelphia, PA: F.A. Davis Company.
Venes, D. (2013). Tabers cyclopedic medical dictionary. (22nd ed.). Philadelphia, PA: F.A. Davis Company.
© 2016 Keith Rischer/www.KeithRN.com
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