History of Present Problem: Elena Acosta is a 54-yr. old Hispanic…

History of Present Problem: 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-sternal chest pain that increased with coughing and developed a harsh productive cough with green phlegm with difficulty breathing. Initial lab results: WBC 14.5, neutrophils 92%, Hgb 12.9, potassium 3.5, creatinine 1.1, total bili 0.9, ALT 42, chest x-ray revealed RLL infiltrate consistent with pneumonia, blood and sputum cultures collected and pending. Smell of ETOH present on her breath. Blood alcohol level 0.04, urine drug screen negative. She is admitted to the medical unit with a diagnosis of pneumonia. You are the nurse responsible for her care. Personal/Social History: Ms. Acosta works in a mid-level management position for a corporate finance company. She describes her job as quite stressful. She drinks 4-5 cups of coffee every day and to least 1-2 alcoholic drinks most days. She states that she shouldn’t smoke and has cut down to about ½ a pack per day. She reports drinking more and sleeping poorly following her father’s death over a year ago. She takes alprazolam as needed for sleep or when she feels more anxious. She is hesitant to be admitted because she has a high deductible insurance plan and doesn’t know how she will be able to afford

Patient Care Begins: Initial Assessment Medical Unit

 

Current VS:	P-Q-R-S-T Pain Assessment:
T: 101.2 F/38.4 C (oral)	Provoking/Palliative:	nothing
P: 96 (regular)	Quality:	ache
R: 28 (regular)	Region/Radiation:	Denies chest pain currently/Headache-global
BP: 138/88	Severity:	5/10
O2 sat: 92% room air	Timing:	constant

Current Assessment:
GENERAL SURVEY:	Looks older than stated age, alert, oriented, pleasant, in no acute distress, calm, body relaxed, no grimacing, appears to be resting comfortably.
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.

 

 

 

Unfolding: Eight Hours After Admission… 

Despite frequent coughing, Ms. Acosta can sleep intermittently. Sputum culture is positive for Streptococcus pneumoniae. To complete the admission assessment, the nurse addresses her ETOH drinking pattern and history. She admits to drinking a lot more lately due to the increased responsibilities of her job. She needs a drink in the morning to “calm herself down”, especially when she hasn’t been able to sleep. Admits to drinking more heavily since her father died a year ago. She doesn’t think she has a problem with drinking, just too much stress. She became so overwhelmed by the constant coughing and chest pain that she had a “drink or two” to “steady her nerves” before coming to the hospital ED. Denies use of alprazolam past week

 

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
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% RA	O2 sat: 94% RA	Timing:	Constant

Answer  following the questions

Describe a situation in the case study that required you, as the nurse, to make a correct clinical judgement in order to either advance the plan of care or recognise clinical data that indicated a change in clinical status.
What can we take away from ii?
What would you do differently if you could?
How you can put this knowledge to use in the future

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