Nursing Case Study: Managing Alcohol Withdrawal and Pneumonia in a 54-Year-Old Patient, Exams of Nursing

Download Nursing Case Study: Managing Alcohol Withdrawal and Pneumonia in a 54-Year-Old Patient and more Exams Nursing in PDF only on Docsity! ETOH Withdrawal-Pneumonia UNFOLDING Reasoning Case Study Questions with Correct Answers 1 Elena Acosta is a 54-yr. old Hispanic woman with hypertension managed with hydrochlorothiazide. She is 63” (160.2 cm) and weighs 175 pounds (79.3 kg-BMI 31.0). She felt “crummy” and weaker the last 24 hours and called 911 when she began to have mid- 2 Elena Acosta, 54 years old Primary Concept Addiction Interrelated Concepts (In order of emphasis) • Infection • Intracranial Regulation • Patient Education • Communication • Collaboration NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Safe and Effective Care Environment • Management of Care 17-23% • Safety and Infection Control % 9-15 Health Promotion and Maintenance 6-12% Psychosocial Integrity 6-12% Physiological Integrity • Basic Care and Comfort 6-12% • Pharmacological and Parenteral Therapies 12-18% • Reduction of Risk Potential 9-15% ✓ • Physiological Adaptation 11-17% ✓ History of Present Problem: NEUROLOGICAL: Alert & oriented to person, place, and situation (x3), knew year, but wrong day of week, feels fatigued with chills, weak, no focal deficits HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. RESPIRATORY: Breath sounds bibasilar crackles posteriorly, diminished aeration R>L bases, nonlabored respiratory effort on room air, productive cough with moderate amount thick yellow/brown tinged sputum CARDIAC: Pink, warm & dry, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-E-T- M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Abdomen round, soft, and nontender. BS + in all 4 quadrants GU: Voiding without difficulty, urine clear/yellow INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill <3 seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present. 3.What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) (worth 3 points) RELEVANT Assessment Data: Clinical Significance: 5 -A&Ox3 -Fatigued with chills -Bibasilar crackles posteriorly -Diminished aeration bases -Productive cough with moderate amount thick yellow/brown sputum -Increased stress levels and decreased sleep can both lead to impaired cognition. - Fatigue and chills are both common signs of infection. -Crackles indicate the presence of fluid in the lungs. - Diminished breath sounds indicate decreased movement of air which may be caused by shallow breathing or an obstruction. -The productive cough is caused by the accumulation of fluid and debris in the airway. The yellow and brown sputum indicates the presence of an infection is likely. Clinical Reasoning Begins… 4. Interpreting relevant clinical data, what is the primary problem? What primary health related concepts does this primary problem represent? (Management of Care/Physiologic Adaptation)(worth 3 points) Problem: Pathophysiology of Problem in OWN Words: Primary Concept: Pneumonia Aspiration or invading microorganisms, usually S. pneumoniae, colonize the Infection alveoli causing an immune response. Antigens-antibody response and endotoxins case damage to the bronchial and alveolar mucous membranes. The damage causes inflammation leading to alveolar edema and exudate formation. The alveoli and bronchioles dill with fluid and infectious debris causing consolidation of the lung tissue. This will interfere with ventilation and compromise gas exchange. 5. Collaborative Care: Medical Management (Pharmacologic and Parenteral Therapies) (worth 8 points) Care Provider Orders: Rationale: Expected Outcome: Supplemental O2 per nasal cannula at 2 L/min. for O2 sat <93 % VS every 4 hours and as needed Levofloxacin 500 mg IV in Sodium chloride 0.9% solution to infuse over 60 minutes Hydrochlorothiazide 50 mg PO daily Acetaminophen 325-650 mg PO every 4 hr. PRN pain/temp >101; not to exceed 4000 mg/day -Inflammation of the alveolar 6 capillary membrane interferes with the diffusion of gases across the membrane. Increasing the percentage of inspired oxygen will help enhance diffusion. (627, Pearson) - Frequent and ongoing respiratory assessments are important for patients with pneumonia. (632, Pearson) - Levofloxacin is an antibiotic that works by stopping bacterial growth. It is commonly used to treat pneumonia. (893, Adams) -Hydrochlorothiazide is an antidiuretic and is used to treat the crackles in the patient’s lungs. (549, Adams) -Acetaminophen is used to reduce the patient’s pain from her head ache. It will also reduce her fever. (735, Adams) -Patient will not show signs of hypoxia and will maintain oxygen levels of 95% or higher. -Signs of deterioration will be caught early. - Symptoms associated with pneumonia will start to improve. - Crackle in the lungs will improve. -The patient’s pain level will stay below 3/10 and temperature will stay below 101. Collaborative Care: Nursing 6.What nursing priority (is) will guide your plan of care? (Management of Care)(Worth 8 points) Nursing PRIORITY: Ineffective airway clearance Ineffective breathing pattern PRIORITY Nursing Interventions: Rationale: Expected Outcome: -Encourage the patient to use an -Incentive spirometer will help expand the lungs, - Crackles will be less incentive spirometer. push free fluid out of the lungs, and strengthen the audible when lungs are -Encourage activity and ambulation as lungs. (131, Ackley) auscultated. tolerated. -Body movement helps mobilize secretions. (132, - Consolidation of the -Coach patient to slow down their Ackley) lungs will improve. Breathing, have them breath with you. -Making the patient aware of respirations and giving -Patient’s respiratory -Position the patient in an upright or support may help them gain control of their rate will decrease to semi-Fowlers position. breathing rate. (183, Ackley) within normal limits. -An upright position allows for maximal lung -Patient will breathe expansion. Lying flat cause’s abdominal organs to more easily and shift toward the chest which can decrease the space ventilation will for the lungs and make breathing more difficult. improve. (184, Ackley) 7 10. What responses from the CAGE assessment are RELEVANT and have clinical significance to the nurse? (Reduction of Risk Potential) (worth 10 points) RELEVANT Data: Clinical Significance: Have you ever felt you needed to Cut down on your -The patient recognizes she has increased the amount drinking? she has been drinking for over a year. “I have been drinking more in the past year since my father died. Yeah, I wonder if I should cut back since it’s been a year since he died.” -Indicate the patient does not have a strong support Have people Annoyed you by criticizing your drinking? system and does not confide in her friends for support. “Since I live alone nobody knows except me about my drinking except me.” Have you ever felt Guilty about drinking? -Indicates the patient is unable to recognize that drinking “I don’t feel guilty about my drinking because I need is not a healthy or effective coping mechanism. something to help me and it’s working for me.” Have you ever felt you needed a drink first thing in the -Indicates the patient feels reliant of alcohol to reduce Morning (Eye-opener) to steady your nerves or to get rid of an anxiety and does not have a health coping for dealing hangover? with her anxiety. “I need a drink in the morning to calm myself down and study my nerves.” Unfolding: Day #2 at 0100… The nurse finds Ms. Acosta fully awake. Reports she was starting to feel better because she was able to rest and eat a little food. Now she feels worse again, but in a “different way”. The nurse completes a focused respiratory assessment and general health assessment. Review the following reported signs and symptoms. Current VS: 4 Hours Ago: Current PQRST: T: 99.0 F/37.2 C T: 98.6 F/37.0 C Provoking/Palliative: Bright lights make pain worse 10 P: 110 (reg) P: 98 (reg) Quality: Throbbing like an elastic band around my head R: 20 (reg) R: 20 (reg) Region/Radiation: headache BP: 154/92 BP: 136/84 Severity: 7/10 O2 sat: 95% RAO2 sat: 94% RA Timing: Constant 11. What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) (worth 3 points) RELEVANT VS Data: Clinical Significance: -Pulse:110 -Increased pulse indicates the patient is experiencing increased distress and pain. -BP-154/92 -Increased blood pressure indicates the patient is experiencing increased stress -7/10, Bright lights make response and pain. pain worse Throbbing -Headache is a very common symptom of alcohol withdrawal and may be caused by the like an elastic band effects long term use and alcohol dependency has on the brain. around my head Current Assessment: GENERAL SURVEY: Dressed in hospital gown; appears uncomfortable; restless; constantly repositioning self in bed NEUROLOGICAL: Alert & oriented to person, and place, did not know where she was or the day of the week; moderate hand tremors when asked to extend both arms HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort; O2 sat: 95% on room air or oxygen? CARDIAC: Pink, warm & dry, no edema, heart sounds regular, pulses strong, equal with palpation 11 at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-E-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Abdomen round, soft, and nontender. BS + in all 4 quadrants, no appetite, upset stomach with nausea; no vomiting GU: Voiding without difficulty, urine clear/yellow INTEGUMENTARY: Forehead moist, skin warm, and intact, normal color for ethnicity. No clubbing of nails, cap refill <3 seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present Mental Status Examination (MSE): APPEARANCE: Moderately overweight woman; Looks fatigued and anxious. Less willing to answer assessment questions currently “Just leave me alone, please”. Disheveled appearance. Reports currently having difficulty sleeping MOTOR BEHAVIOR: Moderate hand tremor when asked to extend arm twitching, reports feeling shaky inside, frequent repositioning noticed SPEECH: Normal rate and rhythm; occasionally slow to respond MOOD/AFFECT: c/o fatigue and mild depression; intense anxiety; 7 out of a possible 10; irritable and tearful at times THOUGHT PROCESS: Linear and logical THOUGHT CONTENT: Preoccupied with physical symptoms; no evidence of delusions PERCEPTION: Denies hallucinations; reports being bothered by bright lights and noise of the unit INSIGHT/JUDGMENT: Difficult to assess at this time; continues to recognize need for hospitalization for symptoms of pneumonia; seems to understand drinking as a coping strategy for increased stress and not a problem by itself COGNITION: Generally oriented but date is off by 2 days SUICIDAL/HOMICIDAL:Denies suicide, homicide or self-harm ideation 12. What clinical data are RELEVANT that must be recognized as clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance) (worth 6 points) RELEVANT Assessment Data: Clinical Significance: 12 verbalize feelings and show (112, Lemon) signs of understanding of feelings. You have done an excellent job identifying the following: • Need to clarify/expand upon initial assessment information • Recognize potential for life-threatening complications • Recognize need to intervene in an emergent way 16. Now finish strong and give the following SBAR report to the health care provider to communicate this change of status. (Management of Care)(worth 8 points) Situation: Name/age: Elena Acosta, 54 year old female BRIEF summary of primary problem: The patient came in with mid-sternal chest pain and a productive cough with difficulty breathing. She was found to heave pneumonia. The patient smelled like alcohol when she came in and 8 hours after admission she began to show signs of withdrawal. Day of admission/post-op #: She was admitted yesterday. Background: Primary problem/diagnosis: The patient has been diagnosed with bacterial pneumonia and is currently going through alcohol withdrawal. RELEVANT past medical history: Hypertension RELEVANT background data: She has a very stressful job and uses alcohol to cope. The amount she drinks has increased after her father died a year ago. She also hasn’t been sleeping well and does not have a strong support system. Assessment: 15 Most recent vital signs: Temp: 99.0F, P: 110, BP: 154/92, O2 sat: 95% on room air, Headache 7/10 RELEVANT body system nursing assessment data: Patient is A&Ox2, Crackles have cleared and breath sounds are now clear, No appetite with nausea but no vomiting. RELEVANT psychosocial assessment data: Hand tremors when extended, Mild depression, Intense anxiety, No evidence of delusions or hallucinations. How have you advanced the plan of care? The pneumonia has been currently managed with medication. Patient has been educated on the negative effects alcohol has on the body and the role it has played in her hospitalization. Healthier coping mechanisms have been suggested. RELEVANT lab values: WBC: 14.5 and Neutrophils: 92% on admission TREND of any abnormal clinical data (stable-increasing/decreasing): Stable- increasing Patient response: Patient has responded well to treatment for pneumonia. However, patient is unable to recognize she has a drinking problem. INTERPRETATION of current clinical status (stable/unstable/worsening): Stable Recommendation: Suggestions to advance the plan of care: Continue to closely monitor progression of withdrawal symptoms. Continue to educate the patient on negative effects of alcohol and healthier coping mechanisms. 16 In response to the assessment and recommendations of the nurse, the primary care provider orders the following: 17. Collaborative Care: Medical Management (Pharmacologic and Parenteral Therapies) (worth 10 points) Care Provider Orders: Rationale: Expected Outcome: Lorazepam 2 mg now. - Benzodiazepines are a first-line therapy used to -The patient will not minimize the discomfort associated with alcohol have a seizure due to Lorazepam 1 mg by mouth (PO) every 4 withdrawal, particularly seizures. (1674, Pearson) withdrawal. hours x 2 days. -Lorazepam is used to minimize the symptoms of -The patient will not withdrawal that appear within a few hours suffer severe Lorazepam 1 mg PO q 1 hr. for breakthrough following cessation of alcohol and peak after 24 to symptoms during the withdrawal symptoms (elevated CIWA 48 hours and then rapidly improve. (105, Lemon) peak of the scores). -PRN Benzodiazepines are useful to treat withdrawal. breakthrough symptoms and prevent the patient -The patient’s Hold and notify provider for sedation prior to from developing delirium tremens from occurring. breakthrough dose. (1673, Pearson) symptoms will be Max dose of 12 mg per 24 hours. -Lorazepam CNS depressant which can cause alleviated and sedation if too much is administered. If severe delirium tremens will Thiamine 1100 mg PO/IV/IM Q8H/TID x 3 sedation of the respiratory system may occur not occur. days, then 100 mg. PO daily leading to a compromised airway. (239, Adams) -The patient will not -Vitamin B is necessary to prevent complications suffer a Folic acid 1 mg daily PO from chronic alcoholism such as Wernicke’s compromised air due Multivitamins 1 tab daily by mouth CIWA scale every 4 hours with VS every 4 hours and PRN as clinically indicated Seizure precautions Fall risk precautions Referral to substance use disorder clinical specialist or psychiatry 17 gives them a sense of belonging and provides them anything that would with a support system. contradict the -The nurse should communicate with the patient patient’s beliefs. about what belief practices are important to them and incorporate them into the patient care. CULTURAL Considerations N/A N/A (IF APPLICABLE) Education Priorities/Discharge Planning 19. What educational/discharge priorities will be needed to develop a teaching plan for this patient and/or family? (Health Promotion and Maintenance) (worth 3 points) Education PRIORITY: Effective coping strategies Negative effects of substance abuse PRIORITY Topics to Teach: Rationale: -The effects alcohol has on the sleep cycle -Alcohol can be one source for why she is sleeping poorly. Although -Alcohol is not a healthy coping mechanism alcohol may help her fall asleep is actually disrupts the sleep stages -Suggest healthier coping mechanisms such as and prevents restorative sleep. yoga or a hot bath. -Using alcohol is used to avoid dealing with stress and does not help or improve the situation. -Stress is inevitable part of life and healthy coping mechanisms are necessary to help us deal with these stressors. Caring and the “Art” of Nursing 20. What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person?(Psychosocial Integrity) (worth 2 points) What Patient is Experiencing: How to Engage: The patient is currently experience high levels The patient should be approached in a nonjudgmental demeanor and of anxiety, distress, agitation, and pain due to should be treated with compassion to prevent alienation. The nurse 20 withdrawal from alcohol. should also show the patient patience and should practice presenting to show the patient you support them and are there if they want to talk. Use Reflection to THINK Like a Nurse 21. What did you learn that you can apply to future patients you care for? Reflect on your current strengths and weaknesses this case study identified. What is your plan to make any weakness a future strength? (Worth 2 points) What Did You Learn? What did you do well in this case study? I learned how overwhelming symptoms of withdrawal I believe I selected relevant nursing diagnosis and identified can be. the most important interventions accordingly. What could have been done better? What is your plan to make any weakness a future strength? I feel like I can improve on the psychosocial/holistic I will invest more time into treating patients as a whole and not care aspect involved in this case study. just as a diagnosis. References Ackley, B., Ludwig, G., Makic, M. (2017) Nursing Diagnosis Handbook An Evidence- Based Guide to Planning Care. 3251 Riverport Lane, MO: Elsevier Adams, M., Urban, C. (2018) Pharmacology: Connections to Nursing Practice. 330 Hudson St, NY: Pearson. Lemon, P., Burke, K., Bauldoff, G., & Gubrud, P. (2015). Medical-Surgical Nursing: Critical thinking in client care. Upper Saddle River, NJ: Prentice Hall. Pearson. (2019). Nursing: A Concept-Based Approach to Learning (Vol 1). 330 Hudson St, NY: Pearson. 21 Potter, M., Moller, M. (2016). Psychiatric-Mental Health Nursing: From Suffering to Hope. 330 Hudson St, NY: Pearson. 22