Major Case Study 2

Running head: MAJOR CASE STUDY

Major Case Study

In partial Fulfillment of the requirements of

NURS-1228

Submitted by

Christine Delany SNRSU

Group A

Submitted to

Ms. Sarah Tune, BSN RN

02/27/2011

Rogers State University

MAJOR CASE STUDY 2

Major Case Study

The patient is an 83 year old Caucasian female with NKDA who was admitted on

02/02/2011 with the diagnoses of: pneumonia, confusion, and bile duct cancer on standard

isolation precautions. Upon questioning the patient, she states “I fell and woke up here, they said

I have pneumonia.” After speaking to the patients’ daughter-in-law, her admission was noted to

be the result of a fall in the home of the patient on the day of admission. She had apparently lain

in the floor of her kitchen until another family member had concerns for her safety and came

over for a visit. When the family member had found her, she was disoriented, and short of

breath. The family member called an ambulance and she was admitted to the floor following an

x-ray, CT scan, peripheral IV insertion and labs drawn in the emergency room. The results of the

labs were supportive of the diagnosis of pneumonia as her WBC is 26.5K/uL on the date of

admission. The CXR confirms pneumonia. The patient is a retired LPN who has no religious or

cultural requests. She lives at home by herself and has family in the area that check on her

frequently. She is of full-code status, has a living will and her driver’s license states she is an

organ and tissue donor. She enjoys reading and her only response to assessing her stress was her

“family and career.” Her medical history consists of hypertension, a disorder in lubrication

which has causes her to have dry eyes, mouth, and joints, osteoarthritis, diabetes, and she has had

a myocardial infarction that was further diagnosed to congestive heart failure. Additionally she

has a history of cancer of the bile duct which required the surgical placement of a stent in her

bile duct on 12/22/2010. Bile duct cancer or “cholangiocarcinoma is a cancerous (malignant)

growth in one of the ducts that carries bile from the liver to the small intestine” (Lewis 2007).

According to Erikson’s psychosocial theory of development, she is believed to be in the integrity

versus despair conflict and has shown to resolve this by possibly maintaining integrity as she has

MAJOR CASE STUDY 3

chosen not to undergo chemotherapy. Despite her fluctuating LOC, she has been classified as a

reliable historian as she answers questions directly and they appear identical to the history

provided in her medical record. She does not smoke or drink and does not engage in recreational

drugs. Her immunizations are up to date and it was further recommended to her that upon

discharge she should get a pneumonia vaccination and she declined to the opportunity.

Head to Toe Assessment

On this clinical day, (02/07/2011) the patient was awake, alert and oriented to person and

place. She responded to questions with clear speech and she seemed rather agitated in her tone of

voice when she asserted “I’ve been in this bed for three days”. Her pupils are 3mm and are equal

bilaterally and after they reacted to light, they were then considered normal in accommodation.

Her affect appeared flat and all together emaciated. Her skin is pink, warm and dry with poor

turgor. Her temperature is 96.6 taken temporally. Additionally a few bruises are noted on the

tops of her hands. Upon inspection, no decubitis are found. Her Braden score is noted at 16

putting her at low risk for pressure ulcers. The patient has one incision on her upper-right flank

that is healing by primary intension as tissue surfaces were approximated and there is minimal

tissue loss. The scar is 3cm in length and this student nurse changed the dressing to a non-

adherent pad with paper tape on 02/07/2011. Her IV site, located in her left forearm appeared

clear but upon saline flush, leaking was noting at the point of insertion. IV site was D/C and

changed by a nurse.

Upon auscultation, bilateral rales are heard that do not clear with cough. This finding is

consistent with the current diagnosis of pneumonia; which is an infection that occurs when fluid

and cells collect in the lung (Lewis, 2007). Her chest rises evenly bilaterally as she takes fast

shallow breaths. Her cough is productive as it produced thick yellow sputum. Her SpO2 is 94%

MAJOR CASE STUDY 4

on 1L oxygen via nasal cannula and respiratory rate is 24 indicating tachypnea. Patient

complained of Orthopnea and the head of the bed was elevated to accommodate.

Inspection of her abdomen revealed flat loose skin, and when questioned for areas of

tenderness she replied “no, none”. Auscultation revealed bowel sounds were positive in 4

quadrants and upon palpation, no rebound tenderness is noted, although the stomach appeared

large and swollen. Her nurse confirmed this was most likely a result of her recent surgery and I

continued to monitor its condition. She reported that she had had a soft small formed bowel

movement this morning and that she usually has one every day. Her oral mucosa was dry as a

result of a lubrication disorder. Her nutritional status is considered poor as her BMI is 18.2. She

consumed 40% of breakfast and 20% of lunch on this clinical day. Her ordered diet is consistent

carbohydrate which was ordered to help her control her diabetes. Her prescribed nutritional

supplement was placed with her lunch. She had a Foley placed upon admission which on this day

contained 30ml of dark amber urine without sediment.

Apical pulse is 67 and the rhythm is regular as only s1 and s2 are noted. Radial pulse was

normal and equal bilaterally and pedal pulses were increased bilaterally. Blood pressure is

103/48 which is comparable to previously recorded data. Capillary refill was assessed on fingers

and toes both of which were greater than 3 seconds in return with no clubbing. Her fluid status

was evaluated and hydration was placed within her reach. Her range of motion is full and she

requires assistance needed for transfers and turning. She used a walker before admission. Gait

was unable to be assessed as full assistance was needed for any and all ambulation. She is weak

on the left side but manages to help when assisted to dangle legs from bed. Because of her

confusion and fall assessment score of 5 putting her at high risk for falls, a bed alarm was

attached. Additional safety measures were taken and included keeping belongings and call light

MAJOR CASE STUDY 5

within reach. She wears glasses, has upper and lower dentures, and did not require hearing aids.

When questioned for presence of pain, she reported yes, but her source was unclear. At one point

she complained of a tight chest, and dry mouth, and then later, complained of leg pain rating both

episodes at 8 on a 1 to 10 scale. The pain she reported was constant and not relieved by any

measure. She requested a “pain pill” (Percocet 5-325), which was given at 1200. Her response

after turning and propping up with pillows was a comfortable nap with no additional needs

voiced. The patient reports a very disturbed sleep as she states “I was up all night coughing”,

therefore the nap she attained following pain relief was therapeutic.

Medications

Home MedicationsReference Drug Average

DoseIndication Adverse Effects Drug Class d

/c

(Wilso

n, Shannon, &

Sheilds,

2010.p 150)

Baclofen 10mg PO TID

PO: 20-80 mg/day div tid-qid

Spasticity CNS Depression Resp. Depression

Muscle Relaxant Y

Darvocet N 100/650mg PO BID

Withdrawn from U.S Nov/2010

Mod-Severe Pain

CNS Depression Resp. Depression,constipation

Opioid Combo’s Y

“p 359” Clonazepam 1mg PO BID

PO: 1-2mg/d in divided dose

Panic Disorders

Respiratory depression, Coma, suicide attempt

Benzodiazepine N

“p 78 &158” Lotrel 5/40mg PO QD

PO:Max: 10/80 mg/day

Hypertension Angioedema (head,neck,intestinal)

CCBs, Dihydropyridine; ACE Inhibitors

*

“p 896” Levothyroxine 125mcg PO QD

PO:50-100mcg/d

Thyroid Replacement

Insomnia; hyperthyroidism effects

Hormone: Thyroid replacement

N

“p 1157” Oxycontin 20mg PO

PO:5-10mg q6h

Mod-Severe Pain

Hepatotoxicity, respiratory

Opiate Agonist Y

https://online.epocrates.com/noFrame/showPage.do?method=drugs&MonographId=915&ActiveSectionId=7#browsercontentbox

https://online.epocrates.com/noFrame/showPage.do?method=drugs&MonographId=915&ActiveSectionId=7#browsercontentbox

MAJOR CASE STUDY 6

Q12h depressionNone Miralax 17gm

Pack PO QDPO:Max:17gm/d

Constipation Electrolyte Imbalance, Laxative dependence

Osmotic Laxative N

None Theravite Multavitamin 1Tab PO QD

PO: 1 tab/d Health Maintenance

Iron Toxicity, Skin Flushing, Vitamin Toxicity

Vitamin and mineral combinations

Y

“p 1135” Omeprazole DR 20mg Cap PO QD

PO:20mg/d Antiulcer/GERD Dyspepsia

Headache, dizziness, diarrhea, fatigue

Proton Pump Inhibitor

N

None Oasis LIQD 1-5 sprays PO QD PRN

PO:2tbl spoons QD

Mineral supplement

Mineral Toxicity, Teeth deposits

Nutritional Supplement

N

None Refresh Tears 1.5% SOLN 1-2 drops OPTH QD PRN

1-2 gtt in eye(s) prn

Dry Eye May occur but none reported

Decongestants/Lubricants, Ophthalmic

N

None Systane 0.4% SOLN 1-2 gtts OPTH QD PRN

1-2 gtt in eye(s) prn

Dry Eye May occur but none reported

Decongestants/Lubricants, Ophthalmic

N

* Physician lowered dose to 5/20mg PO QD and switched to generic formulation

Hospital Medications

Reference Drug Average Dose Indication Adverse Effects Drug Class

(Wilso

n, Shannon, &

Sheilds, 2010.

p 872.)

Protonix 40mg PO QAM-AC

Maint. dose 40-80 mg/day

Antiulcer/GERD Dyspepsia

Headache, dizziness, diarrhea, fatigue

Proton Pump Inhibitor

“p 359” Klonopin 1mg PO BID

PO: 1-2mg/d in divided dose

Panic Disorders Respiratory depression, Coma, suicide attempt

Benzodiazepine

“p 891” Levaquin 750-5mg/ 150ml D5W IV [DR-

IV: 750mg Q24h x 5D

Community Acquired Pneumonia

Injection site pain, chest or back pain, rash

Antibiotic; Quinolone

MAJOR CASE STUDY 7

150ml/h] Q24h

“p 1589” Vancomycin HCL 1000mg/NaCl 0.9% 250ml IV [DR-125ml/h] Q12h

IV: 1gm q12h Systemic Infection

Ototoxicity, Nephrotoxicity, Shock-like State, Red-Mans Syndrome, Thrombophlebitis

Antibiotic; Glycopeptide

None Miralax 17gm Pack PO QD

PO:Max:17gm/d

Constipation Electrolyte Imbalance, Laxative dependence

Osmotic Laxative

PRN Drug

“p 459” Robitussin DM 100-10mg/5ml PO Q4-6h PRN

PO:10-20mg Q4h

Cough that inhibits sleep

Dizziness, drowsiness, CNS Depression

Antitussive

“p 1669” Percocet 5-325 tab PO Q4h PRN

PO: 5-10mg Q6h PRN

Mod-Severe Pain

Hepatotoxicity, respiratory depression, sedation

Opiate Agonist/Analgesic

“p 1137” Zofran 4mg IVP Q6h PRN

IVP:4-8mg Q6-8h

N/V Headache, sedation,

Antiemetic

The patient is compliant with ordered medications. The patients overall polypharmacy

regimen is effective for treating Community acquired pneumonia, hypertension, hypothyroidism,

nausea, constipation, pain, dyspepsia, anxiety, a disorder in lubrication and effectively promotes

her health. The overall effectiveness of her polypharmacy is established via standardized tests,

lab results and positive patient verbalization. Problems indicated in the regimen are few and are

due to the potentiating effects of the drug combinations.

The physician discontinued Baclofen for her stay in the hospital most likely because of

the additive effects it could have caused her to have while taking Klonopin and Percocet.

MAJOR CASE STUDY 8

Klonopin, Percocet and Baclofen all have an adverse effect of respiratory depression and CNS

depression.

The effectiveness for Klonopin is minimal as on this clinical day, this student nurse

witnessed verbalizations from the patient that seem agitated indicating anoxolytic effects of the

drug were minimal. Lotrel is considered effective as the patient’s blood pressure is 103/48 using

a electric aneroid sphygmomanometer. Although though no labs were drawn, Levothyroxine is

considered effective as the patient did not exhibit any symptoms of hypo-, or hyperthyroidism.

Miralax is effective in this patient as she produced a small formed bowel movement on this

clinical day’s morning. Omeprazole is effective as an antidyspeptic agent as the patient did not

verbalize to the contrary. Refresh and Systane effectively controlled her disorder of lubrication in

her eyes as she did not verbalize to the contrary. Levaquin and Vancomycin were effective in

reducing symptoms of community acquired pneumonia, and pathogenic microbes in the patient

as leukocytes in the blood obtained for CBC were reduced from 26.5K/ul to 18.6K/ul in a matter

of 48 hours. Regarding Zofran and Robitussin, this student nurse did not witness any doses given

to the patient on any clinical day therefore effectiveness cannot be established.

Treatments

Respiratory Treatment Frequency What it provides for the patientDuoneb 3mg/3ml INH Every 2 hours

PRNRelief from SOB on an as needed basis

Duoneb 3mg/3ml INH Q 4X Daily Opportunity for lung clearance at least four times a day

Treatment Indication What it provides for the patientAYR Saline Nasal Gel applied to lips PRN

Dryness Improved skin integrity during oxygen therapy promoting comfort and reducing the risk of infection

Dietary Supplement BID AC Malnutrition A nutrient dense food before other possibly less dense foods are introduced

IV Site Check Every 72 Hours A lowered risk of phlebitis, extravasationsFlulaval Injection As Needed An opportunity to become actively

immune to the flu (generally offered at

MAJOR CASE STUDY 9

discharge)Pneumovax Injection As Needed An opportunity to become actively

immune to the current pneumonia (generally offered at discharge)

Laboratory

Hematology

Feature 02/05/11 02/04/11 02/02/11 Range Reason ReferenceWBC 18.6 K/ul 16.8 K/ul 26.5 K/ul 4.8 - 10.8 Infection (Malarkey, & McMorrow,

2005, p. 226)%SEG 86.6%G 90.5%G 92.9%G 10 - 92 (Malarkey, & McMorrow,

2005, p. 680)%LYMPHS 4.58%L 2.74%L 1.16%L 20.0 -51.1 Terminal

Cancer(Malarkey, & McMorrow, 2005, p. 680)

%MONO 8.21% 6.03% 5.59% 0.0 - 10.0 (Malarkey, & McMorrow, 2005, p. 680)

%EOSIN 0.251% 0.481% 0.00% 0 - 7.0 (Malarkey, & McMorrow, 2005, p. 680)

%BASO 0.351% 0.240% 0.351% 0 - 2.5 (Malarkey, & McMorrow, 2005, p. 680)

RBC 3.50M/ul 3.64 M/ul 4.57 M/ul 4.20 –6.10 Anemia (Malarkey, & McMorrow, 2005, p. 226)

HGB 9.95g/dl 10.6 g/dl 13.1 g/dl 12.0 –16.0 Anemia (Malarkey, & McMorrow, 2005, p. 226)

HCT 31.5 % 33.0% 41.2% 36 – 48 Anemia (Malarkey, & McMorrow, 2005, p. 226)

MCV 89.9fL 90.5 fL 90.0 fL 81.0 –99.0 Iron deficiency

Anemia

(Malarkey, & McMorrow, 2005, p. 226)

MCH 28.4PG 29.0 PG 28.6 PG 28.0 –35.0 (Malarkey, & McMorrow, 2005, p. 226)

MCHC 31.5g/dl 32.0 g/dl 31.8 g/dl 33.0 –37.0 (Malarkey, & McMorrow, 2005, p. 226)

RDW 12.1% 12.1% 12.1% 11.5 –14.5 (Malarkey, & McMorrow, 2005, p. 226)

PLTCT 320K/ul 324 K/ul 336 K/ul 130 – 400 (Malarkey, & McMorrow, 2005, p. 680)

SEGS 94% 85% 94% 50 – 70 Bacterial Infxn or Cancer


BANDS% 0% 7% 0% 0 – 4 Bacterial (Malarkey, & McMorrow,

MAJOR CASE STUDY 10

Infxn or Cancer

2005, p. 680)

LYMPHS% 5% 4% 1% 20.0 –51.1 Terminal Cancer


MOMO% 1% 2% 5% 0 – 12 (Malarkey, & McMorrow, 2005, p. 680)

EOS% 0% 2% 0% 0 – 4 (Malarkey, & McMorrow, 2005, p. 680)

BASO% 0% 0% 0% 0 – 2.5 (Malarkey, & McMorrow, 2005, p. 680)

Chemistry

Feature 02/05/11 02/04/11 02/02/11 Range Reason ReferenceGlucose 95mg/gl 103 mg/gl 146mg/gl 80 – 150 (Malarkey, & McMorrow,

2005, p.351)BUN 22mg/dl 24mg/dl 26mg/dl 8 - 23 Stress

Dehydration(Malarkey, & McMorrow, 2005, p. 644)

CREAT 0.8mg/ul 0.8 mg/ul 0.7mg/ul 0.7 – 1.5 (Malarkey, & McMorrow, 2005, p. 246)

NA 131mmol/L 132mmol/L 132mmol/L 137 –145 Hypothyroidism


K 3.9mmol/L 3.8 mmol/L 3.9mmol/L 3.6 – 5.0 (Malarkey, & McMorrow, 2005, p. 537)

CL 102mmol/L 101mmol/L 99mmol/L 98 – 107 (Malarkey, & McMorrow, 2005, p. 197)

CO2 25mmol/L 25 mmol/L 23mmol/L 22 – 30 (Malarkey, & McMorrow, 2005, p. 174)

CA 8.2mg/dl 8.6 mg/dl 9.1mg/dl 9.4 –10.2 Hypoalbuminemia


TP 4.7g/dl 6.3 – 8.2 Protein Deficiency


ALB 2.3g/dl 3.2 – 5.0 Infection and fever/Cancer/Malnutrition


SGOT 45U/L 8 – 57 Healing Bone Fracture, Bile Duct Cancer


SGPT 41 U/L 9 – 72 (Malarkey, & McMorrow, 2005, p. 112)

MAJOR CASE STUDY 11

ALKP 189 U/L 38 – 126 (Malarkey, & McMorrow, 2005, p. 59)

BILIT 0.8mg/dl 0.2 – 1.3 (Malarkey, & McMorrow, 2005, p. 122)

GFR 69 69 80 88 - 128CPK 470U/L 30 - 170 Recent

injection, Recent Billiary shunt placement


Urinalysis

Feature 02/06/11 02/02/11 Range Reason ReferenceColor Other Yellow Yellow Bacteriuria (Malarkey, & McMorrow, 2005, p.

652)Clarity Turbid Clear Clear Bacteriuria (Malarkey, & McMorrow, 2005,

p.652)Glucose Negative Negative Negative (Malarkey, & McMorrow, 2005, p.

652)Bili Small Negative Negative Bile Duct

Surgery(Malarkey, & McMorrow, 2005, p. 652)

Keytones Trace Negative Negative Malnutrition (Malarkey, & McMorrow, 2005, p. 652)

USPGRAV >=1.030 1.025 1.000 –1.030 (Malarkey, & McMorrow, 2005, p. 652)

PH 6.0 5.5 4.5 – 7.8 (Malarkey, & McMorrow, 2005, p. 652)

URN Protein

>=300 30 Negative Impaired Kidney Function


UroBilogen 1.0EU/dL 0.2EU/dL 0.1 – 1.1 (Malarkey, & McMorrow, 2005, p. 652)

Nitrate Negative Negative Negative (Malarkey, & McMorrow, 2005, p. 652)

Blood Large Trace-Intact Negative Foley Catheter


Leuko Negative Negative Negative (Malarkey, & McMorrow, 2005, p. 652)

CULT? None None None (Malarkey, & McMorrow, 2005, p. 652)

WBC 0 - 1 0 0 – 5 (Malarkey, & McMorrow, 2005, p. 652)

MAJOR CASE STUDY 12

RBC TNTC 0 0 - 5 Foley Catheter Insertion


Bacteria 0 0 Negative (Malarkey, & McMorrow, 2005, p. 652)

Epith Cl 2 - 4 0 – 2 Few Epithelial Casts


Casts 0 0 0-4 (Malarkey, & McMorrow, 2005, p. 652)

Crystals 0 0 Few Malarkey, & McMorrow, 2005, p.652)

Amorph. 3+ 0 0 Slightly Acidic Urine


Microbiology

Feature 02/02/11 ReferenceInfluenzas A & B Negative None

Vancomycin Studies

Feature 02/06 1532 02/06 1135 02/02 1715 Range Reason ReferenceCKMB 15.9units/l 0.0 – 10.4 Cancer,

Surgery(Malarkey, & McMorrow, 2005, p. 180)

Troponin 0.0pg/ml 0.0 – 0.2 (Malarkey, & McMorrow, 2005, p. 180)

BNATPEP 479.78pg/dl 0 – 100 CHF, Acute MI


Vanco-PK 39.27ug/ml 30 - 40 (Malarkey, & McMorrow, 2005, p. 697)

Vanco-TR 17.66ug/ml 5 - 10 Impaired Excretion


Diagnostic Studies

Chest X-ray done in ER was positive for pneumonia in both lungs on 02/02/2011.

Pathophysiology

MAJOR CASE STUDY 13

“Cholangiocarcinoma (CCA) is a malignant tumor arising from the malignant

transformation of cholangiocytes, the epithelial cells lining the biliary tree” (Gatto, & Alvaro,

2010). The incidence of this disease is rare in Western countries such North America where

there are approximately 2500 cases annually (Krokidis, Fanelli, Orgera, Bezzi, & Passariello,

2010). It is the second most common cancer in the hepatobiliary region but is considered rare

because it accounts for less than 2% of all human malignancies (Krokidis, Fanelli, Orgera, Bezzi,

& Passariello, 2010). The etiology associated with CCA is varied by country. China, Japan,

Korea, Vietnam, Thailand, Laos, and Cambodia have done studies attributing the malignancy to

Clonorchis sinensis, Opisthorchis viverrini, (two types of helmith organisms) and HBV or HCV

infections(Hai-Rim, Jin-Kyoung, Masuyer, Curado, & Bouvard, 2010). In America, the HBV

and HCV viruses were somewhat reduced with vaccinations in the early 1970’s (Hai-Rim, Jin-

Kyoung, Masuyer, Curado, & Bouvard, 2010). America attributes the prevalence of CCA to

cirrhosis, chronic non-alcoholic liver disease, primary scleosing cholangitis (PSC), obesity, and

hepatolithasis (Gatto, & Alvaro, 2010). These risk factors are not presented in patients 90% of

the time as most patients with CCA are asymptomatic (Hai-Rim, Jin-Kyoung, Masuyer, Curado,

& Bouvard, 2010). CCA was discovered in the US when iatrogenic exposure of Throtrast

(thorium dioxide), a radiocontrast agent used in the 1950’s and 1960’s led to reports of CCA in

the 1970’s (Gatto, & Alvaro, 2010). Another emerging theory explaining the etiology of the

disease is the presence of an abnormal biliary-pancreatic junction causing the pancreatic juice

and bile to mix forming lysolecithin (Gatto, & Alvaro, 2010). Lysolecithin then acts as a

detergent on the biliary epithelium which causes chronic inflammation to the bile duct and

eventually, malignancy is formed after the constant regeneration of tissue for an extended

MAJOR CASE STUDY 14

amount of time (Gatto, & Alvaro, 2010).. The abnormal junction was found in one study to be

prevalent 44.8% of the time (Gatto, & Alvaro, 2010).

The clinical manifestations of CCA in this patient are unknown as she was diagnosed

with the malignancy previously to this admission to the hospital, but generally most patients who

are not asymptomatic present with: abdominal pain, diminished appetite, weight loss, malaise,

night sweats, cholestasis, and (or) a palpable hepatic mass(Gatto, & Alvaro, 2010).

Unfortunately, treatment options are minimal as most patients are asymptomatic up until the final

stages of the disease. During these stages, treatment is palliative and includes the placement of a

shunt (either Viabil or uncovered wallstent) to keep the bile ducts patent (Krokidis, Fanelli,

Orgera, Bezzi, & Passariello, 2010). Viabil stent placement versus uncovered wallstent

placement improved the outlook of patients by increasing the length of survival from 180.5 days

(wallstent) to 243.5 days (Viabil) (Krokidis, Fanelli, Orgera, Bezzi, & Passariello, 2010). If

caught early enough, complete surgical resection of the tumor improves patient outlook although

>5% of operated patients will survive 5 years (Krokidis, Fanelli, Orgera, Bezzi, & Passariello,

2010). No study has been established to evaluate the survival rate of those with CCA who have

undergone liver transplant. Additionally, without surgical intervention, body wasting occurs and

prognosis is limited to 12 months(Krokidis, Fanelli, Orgera, Bezzi, & Passariello, 2010).

Nursing Plan of Care

Nursing Diagnosis

MAJOR CASE STUDY 15

Ineffective Airway Clearance related to copious and tenacious tracheobronchial secretions

secondary to Community Acquired Pneumonia as manifested by rales in bilateral upper lung

fields, excessive secretions, and ineffective cough.

Rationale for nursing diagnosis.

According to Maslow’s hierarchy of needs, a patent airway is the highest priority in life

(Gulanick, & Myers, 2010. p 429). This being said, a diagnosis of ineffective airway clearance is

the highest priority to receive interventions in this selected patient. The patient presents with

rales in bilateral lung fields, constant coughing impairing the ability to sleep, and thick yellow

sputum. These characteristics of her pneumonia define the selected nursing diagnosis and require

this student nurses’ immediate attention when conducting assessments, monitoring the patient,

and selecting interventions.

Expected outcome.

Patient will maintain clear open airways as evidenced by normal breath sounds, normal rate and

depth of respirations, and ability to effectively cough up secretions after treatments and deep

breaths by the end of the clinical day on 02/07/2011.

Nursing interventions.

Intervention #1

Assess airway for patency (Done)

A.) Diminished breath sounds or presence of adventitious sounds may indicate an

obstructed airway (Gulanick, & Myers, 2010. p 429).

B.) This student nurse auscultated all lungs fields as part of the shift assessment and

detected the presence of rales in the bilateral upper lung fields.

C.) The patient tolerated the assessment well.

MAJOR CASE STUDY 16

Intervention #2

Instruct the patient on the importance of ambulation and frequent position changes (done)

A.) Ambulation helps maintain adequate lung expansion, mobilizes secretions, and

reduces atelectasis (Balas, Casey, & Happ, 2009).

B.) This student nurse positioned the patient twice during the clinical day with pillows

and the patient reverbalized why it was necessary to reposition frequently.

C.) Patient not only tolerated the procedure well, but was able to settle into a nap after

repositioning and achieving comfort.

Intervention #3

Teach the patient coughing, breathing, and splinting techniques (done)

A.) These techniques facilitate clearance of secretions and prevent atelectasis. Dyspnea

may be reduced by pursed-lip breathing or diaphragmatic breathing (Balas, Casey, &

Happ, 2009).

B.) Pillows used for positioning were also used as instructional models for teaching how

to cough more effectively by the use of splinting. Pursed-lip breathing was explained

and demonstrated to the patient but the patient refused a return demonstration.

C.) Aside from confusion of the mechanism of pursed-lip breathing, the patient tolerated

the procedure well and return demonstrated splinted coughing.

Intervention #4

Administer medications as ordered, noting effectiveness and side effects (done)

A.) A variety of medications are available to treat specific problems. Most promote

clearance of airway secretions and may reduce airway resistance (Gulanick, & Myers,

2010. p 430).

MAJOR CASE STUDY 17

B.) This student nurse administered all medications due during the clinical day and

noticed easier breathing, less pain while coughing and the patient experienced no side

effects.

C.) Patient tolerated medication administration and absorption well with no side effects

or complaints.

Intervention #5

Provide opportunity for increased fluid intake (done)

A.) Increasing the amount of desired fluids to the patient gives them more of a choice to

decide which fluid they should intake, thus increasing fluid intake overall and helping

to thin secretions (Mentes 2008).

B.) This student nurse assessed the patient for drink preference, then consulted dietary

who accommodated the request. The patient consumed 296ml of hot tea with honey

this clinical day.

C.) The patient demonstrated a more relaxed affect and had a more productive cough that

resulted in less frequent coughing fits with greater sputum removal and an increased

amount of rest between coughs.

Nursing Diagnosis

Impaired gas exchange related to altered oxygen supply secondary to community acquired

pneumonia as manifested by oxygen saturation levels of 84% (on admission), confusion,

restlessness and irritability.


Airway may be the upmost priority but the ability for alveoli to exchange oxygen is

second in the requirements of respiration (Marieb, & Hoehn, 2008. p 729). Upon admission to

MAJOR CASE STUDY 18

the emergency department, the patient had oxygen saturation levels at 84%. Since then, x-ray

studies of the chest have concluded pneumonia which is altering the way her body exchanges

oxygen and co2 by filling the alveoli with fluid. Without interventions, this patient could decline

into a state of hypoxia resulting in irreversible brain and lung damage or worse, including death.

Expected outcome

Patient maintains optimal gas exchange as evidenced by SpO2 levels above 90%, alert

responsive mentation, relaxed breathing, and a baseline heart rate of 82 beats per minute by the

end of the clinical day on 02/07/2011.

Nursing Interventions.

Intervention #1

Assess for tachycardia, restlessness, irritability, diaphoresis, headache, visual disturbances, and

confusion (done)

A.) These are early nonpulmonary signs of hypoxia; lethargy and somnolence are late signs.

Cognitive changes may occur with chronic hypoxia (Mentes 2008).

B.) This student nurse witnessed varying amounts of confusion with the patient and during

these episodes attached a SpO2 monitor to the finger of the patient in order to better

assess her respiratory status. A correlation was then found between confusion, SpO2

levels, and the availability of oxygen via nasal cannula.

C.) After reattaching the oxygen, the patient seemed less confused and more comfortable

with a SpO2 level of 94%.

Intervention #2

Teach the need to restrict and pace activities to decrease oxygen consumption during acute

episodes (done)

MAJOR CASE STUDY 19

A.) Energy conservation during episodes of respiratory distress reduces fatigue and Dyspnea

thus allowing more productive oxygenating breaths (Gulanick, & Myers, 2010. p 432).

B.) This student nurse did witness and acute exacerbation of respiratory distress and did

educate the patient on the risks associated with trying to walk while suffering from

hypoxia. The patient did not understand but submitted to remaining still while the nasal

cannula was reapplied.

C.) The patient during the teaching session suffered from confusion and did not reverbalize

why she needed to pace herself; But after correcting the hypoxia the patient did say she

needed to rest.

Intervention #3

Pace activities and schedule rest periods to prevent fatigue. Assist with activities of daily living

(Done)

A.) Activities will increase oxygen consumption and should be planned so the patient does

not become hypoxic (Gulanick, & Myers, 2010. p 429).

B.) This Student nurse managed to adequately pace activities by separating necessary nursing

care by 30 minutes for each activity. Activities paced include: Giving the patient a

shower, changing the gown of the patient, the shift assessment, changing the dressing of

the patients flank incision, and allowing visitors for company to the patient.

C.) The patient tolerated all activities well and SpO2 levels remained above 90% with the

exception of a shower where they dropped to 89%.

Intervention #4

Maintain oxygen administration device as ordered, attempting to maintain oxygen saturation at

90% or greater (done)

MAJOR CASE STUDY 20

A.) Supplemental oxygen may be required to maintain PO2 at an acceptable level (Gulanick,

& Myers, 2010. p 429)

B.) This student nurse did reapply the patient’s nasal cannula delivering 1L of oxygen many

times throughout the clinical day with much success as the patient maintained well above

90% oxygen the entire clinical day excluding the shower where this student nurse

obtained permission to remove the patient from oxygen which resulted in a SpO2 level of

89%.

C.) The patient tolerated the repositions with minimal discomfort after Band-Aids were

reapplied to the cheeks of the patient to maintain skin integrity

Intervention #5

Assess the patient's ability to cough effectively to clear secretions. Note quantity, color, and

consistency of sputum (done)

A.) Retained secretions impair gas exchange and changes in color depict changes in the status

of the infection (Gulanick, & Myers, 2010. p 429)

B.) This student nurse did provide tissue at all times during the clinical day of her care. In

doing so, the patient did use the tissue to expectorate. While the patient slept, this student

nurse did don gloves and examined the tissues containing expectorated sputum. The

sputum at the beginning of the clinical day did contain dark yellow sputum with tan

streaks, and at the end of the clinical day did contain lighter color sputum without streaks.

The sputum assessment allowed for accurate further intervention in the action of

obtaining a more desired hydration fluid for the patient.

C.) The patient was unaware of the intention to examine the sputum but otherwise did not

have difficulty expectorating into the provided tissue.

MAJOR CASE STUDY 21

Nursing Diagnosis

Imbalanced Nutrition: Less than body’s requirements related to increased metabolic needs

caused by disease process and unwillingness to eat secondary to pneumonia and

cholangiocarcinoma as manifested by documented inadequate caloric intake with offered

hospital meals, BMI of 18.2 and low albumin level of 2.3.


Adequate nutrition is required to meet the body’s demands (Dune 2008. p 1272).

When a patient is experiencing the physiological stress of illness, an increase in nutrients is

necessary to keep up with the supply and demand (Dune, 2008. p 1272). Although nutritional

status is not as high of a priority as airway clearance or gas exchange, it is equally vital that the

patient maintain adequate nutrition to promote the return of the body to a homeostatic state of

wellness. This patient having a BMI of 18.2 puts her at an increased risk for an array of

malnutrition related deficiencies thus affecting the way the cells in her body do work. When the

work to be done is fighting off infection, malnutrition can allow the infection to linger by

inhibiting cellular metabolism and causing weakness in the patient thus affecting ambulation thus

promoting atelectasis (Dune, 2008. p 1269).

.

Expected outcome.

Patient reverbalizes importance of nutrient dense foods, shows motivation for achieving

weight within 10% of optimal BMI, and shows improved strength when ambulating to dangle at

bedside by the end of the clinical day on 02/07/2011.

Nursing interventions.

Intervention #1

MAJOR CASE STUDY 22

Document actual weight and height, then inform patient of the findings to assess and invoke

motivation in attaining optimal nutritional status (done)

A.) Patients may be unaware of their actual weight and height or weight loss due to

estimating weight (Dimaria-Ghalili, & Peggi, 2008)

B.) This student nurse did weight the client but did not measure the height of the patient. This

student nurse then did inform the patient of her actual weight of 109lbs. The patient did

not seem surprised but rather seemed reminded of her current nutritional status.

C.) The patient experienced the emotional weight of her situation and verbalized an increased

motivation for attaining a satisfactory nutritional status.

Intervention #2

Monitor significant lab values suggestive of malnutrition such as serum albumin, red blood

counts, white blood counts, and serum electrolyte values (done)

A.) This test indicates degree of protein depletion (2.5 g/dL indicates severe depletion; 3.8 to

4.5 g/dL is normal) (Gulanick, & Myers, 2010. p 432). Anemia and leukopenia occur in

malnutrition, leading to weakness and are usually decreased in malnutrition, (Dune,

2008), indicating anemia and decreased resistance to infection (Malarkey, & McMorrow,

2005, p. 226). Potassium is typically increased and sodium is typically decreased in

malnutrition (Malarkey, & McMorrow, 2005, p. 537).

B.) This student nurse did note lab values associated with malnutrition and did note the

values of minerals contained in the ordered dietary supplement. Lab results were

suggestive of malnutrition (see laboratory). Dietary supplement values were adequate for

replacing low albumin, potassium, iron, calcium, and magnesium.

MAJOR CASE STUDY 23

C.) Patient did tolerate venipuncture well as noted in patient care notes as this student nurse

was not present for the ordered nursing activity.

Intervention #3

Involve patients in all aspects of their nutritional care (observed)

A.) Involving patients in their own nutritional care has been found to raise their intake of

protein and energy levels (Dimaria-Ghalili, & Peggi, 2008)

B.) This student nurse did witness dietary ask the patient which meal items she would prefer

and provided her with such.

C.) The patient seemed to enjoy being included in the process of determining what she would

consume with each meal. It allowed her to make appropriate choices that were

individualized to her energy levels and oxygen needs.

Intervention #4

Teach patient how to select nutrient dense foods, what caloric intake would be adequate for her

condition, and provide information on the food pyramid (planned)

A.) Patients may not understand what is involved in a balanced diet. They are better able to

ask questions and seek assistance when they know basic information (Dimaria-Ghalili, &

Peggi, 2008)

B.) Success in this intervention would have been witnessed as a positive reverbalization of

teaching, and following the teaching; the accurate choosing of nutrient dense foods that

supported an adequate caloric intake.

MAJOR CASE STUDY 24

C.) The patient would presumably do very well as long as she had motivation for learning

and did not seem confused or under distress,

Intervention #5

Provide companionship during mealtime (done).

A.) Attention to the social aspects of eating is important in both the hospital and home

settings (Gulanick, & Myers, 2010. p 429).

B.) This student nurse did sit at eye level while the patient ate and provided emotional

support, therapeutic communication, and situational levity.

C.) The patient did prefer this student nurse and her niece to be present while eating and

tolerated the company well.

Evaluation of Nursing Diagnosis

Nursing diagnosis #1

Patient maintained clear open airways as evidenced by normal breath sounds, normal rate

and depth of respirations, and effectively coughed up secretions after treatments and deep breaths

by the end of the clinical day on 02/07/2011. (Met)


Patient maintained optimal gas exchange as evidenced by SpO2 levels at 94%, alert

responsive mentation, relaxed breathing, and a baseline heart rate of 82 beats per minute by the

end of the clinical day on 02/07/2011.(Met)


MAJOR CASE STUDY 25

Patient showed motivation for achieving weight within 10% of optimal BMI, and showed

improved strength when she ambulated to dangle at bedside by the end of the clinical day on

02/07/2011. (Partially Met)

Long Term Goal

The best possible outcome for this client would be for her to remain as comfortable as

possible during her disease process in the company of her family and friends. Additionally, her

dignity throughout her palliative care would remain intact and this all would be evidenced by her

discharge to family and (or) friends, where she would have positive verbalizations reflecting

upon her life until she experiences a peaceful death.

Evaluation of Experience with the Patient

This was this student nurse’s first experience with a terminal illness. Knowledge is

gaining in this student nurse in the areas of palliative care, bile duct malignancies, lab results and

alternative treatment options surrounding palliative care. Although the patient remained confused

regularly throughout the duration of the clinical days with this patient, the times when she was

not were interesting as she talked about her life and children. Situational levity remained

appropriate and was appreciated as it assisted with her coping mechanisms already in place.

MAJOR CASE STUDY 26

References

Balas, M.C., Casey, C.M., & Happ, M.B. (2009). Comprehensive assesment and management of

the critically ill. Informally published manuscript, New York University, New York,

New York. Retrieved from

http://consultgerirn.org/topics/critical_care/want_to_know_more

Dunne, A. (2008). Malnutrition and the older adult: care planning and management. (Cover

story). British Journal of Nursing (BJN), 17(20), 1269-1273. Retrieved from

EBSCOhost.

Dimaria-Ghalili, R.A., & Peggi, P. A. (2008). How to try this: the mini nutritional assessment.

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Gatto, M., & Alvaro, D. (2010). Cholangiocarcinoma: risk factors and clinical presentation.

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585

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Lewis RL. Liver and biliary tract tumors. In Goldman L, Ausiello D, eds. Cecil Medicine.

(2007)23rd ed. Philadelphia, Pa: Saunders Elsevier;:chap 206.

MAJOR CASE STUDY 27

Malarkey, L. M., & McMorrow, M. E. (2005). Saunders nursing guide to laboratory and

diagnostic tests. St. Louis, MO: Saunders Elsevier

Marieb, E. N., & Hoehn, K. (2008). Anatomy & physiology. San Francisco, CA: Benjamin

Cummings.

Mentes, J. C. (2008). Hydration management. Informally published manuscript, College of

Nursing, New York, New York. Retrieved from

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Wallace, M., & Shelkey, M. (2008). Why assess older adults’ ability to perform. American

Journal of Nursing, 108(4), 67-70.

Wilson, B.A., Shannon, M.T., & Sheilds, K. M. (2010). Pearson nurses's drug guide 2010. New

york, New york: Pearson Inc.

Documents

Major Case Study 2