NRNP 6540 Week 5 Case Assignment: A 67-year-old With Tachycardia and Coughing
Case Title: A 67-year-old With Tachycardia and Coughing
Ms. Jones is a 67-year-old female who is brought to your office today by her daughter Susan. Ms. Jones lives with her daughter and is able to perform all activities of daily living (ADLs) independently. Her daughter reports that her mother’s heart rate has been quite elevated, and she has been coughing a lot over the last 2 days. Ms. Jones has a 30-pack per year history of smoking cigarettes but quit smoking 3 years ago.
Other known history includes chronic obstructive pulmonary disease (COPD), hypertension, vitamin D deficiency, and hyperlipidemia. She also reports some complaints of intermittent pain/cramping in her bilateral lower extremities when walking, and has to stop walking at times for the pain to subside. She also reports some pain to the left side of her back, and some pain with aspiration.
Ms. Jones reports she has been coughing a lot lately, and notices some thick, brown-tinged sputum. She states she has COPD and has been using her albuterol inhaler more than usual. She says it helps her “get the cold up.” Her legs feel tired but denies any worsening shortness of breath. She admits that she has some weakness and fatigue but is still able to carry out her daily routine.
Vital Signs: 99.2, 126/78, 96, RR 22
Labs: Complete Metabolic Panel and CBC done and were within normal limits
CMP Component Value CBC Component Value
Glucose, Serum 86 mg/dL White blood cell count 5.0 x 10E3/uL
BUN 17 mg/dL RBC 4.71 x10E6/uL
Creatinine, Serum 0.63 mg/dL Hemoglobin 10.9 g/dL
EGFR 120 mL/min Hematocrit 36.4%
Sodium, Serum 141 mmol/L Mean Corpuscular Volume 79 fL
Potassium, Serum 4.0 mmol/L Mean Corpus HgB 28.9 pg
Chloride, Serum 100 mmol/L Mean Corpus HgB Conc 32.5 g/dL
Carbon Dioxide 26 mmol/L RBC Distribution Width 12.3%
Calcium 8.7 mg/dL Platelet Count 178 x 10E3/uL
Protein, Total, Serum 6.0 g/dL
Albumin 4.8 g/dL
Globulin 2.4 g/dL
Bilirubin 1.0 mg/dL
AST 17 IU/L
ALT 15 IU/L
Allergies: Penicillin
Current Medications:
ï‚· Atorvastatin 40mg p.o. daily
ï‚· Multivitamin 1 tablet daily
ï‚· Losartan 50mg p.o. daily
ï‚· ProAir HFA 90mcg 2 puffs q4–6 hrs. prn
ï‚· Caltrate 600mg+ D3 1 tablet daily
Diagnosis: Pneumonia
Directions: Answer the following 10 questions directly on this template.
Question 1: What findings would you expect to be reported or seen on her chest X-ray results, given the diagnosis of pneumonia?
Question 2: Define further what type of pneumonia Ms. Jones has, HAP (hospital-acquired pneumonia) or CAP (community-acquired pneumonia)? What’s the difference/criteria?
Question 3:
3A) What assessment tool should be used to determine the severity of pneumonia and treatment options?
3B) Based on Ms. Jones’ subjective and objective findings, apply that tool and elaborate on each clinical factor for this patient.
Question 4: Ms. Jones was diagnosed with left lower lobe pneumonia. What would your treatment be for her based on her diagnosis, case scenario, and evidence-based guidelines?
Question 5: Ms. Jones has a known history of COPD. What is the gold standard for measuring airflow limitation?
Question 6: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain/cramps. Which choice below would be the best choice for a potential diagnosis for this? Explain your reasoning.
a. DVT (Deep Vein Thrombosis)
b. Intermittent Claudication
c. Cellulitis
d. Electrolyte Imbalance
Question 7: Ms. Jones mentions intermittent pain in her bilateral legs when walking and having to rest to stop the leg pain. What test could be ordered to further evaluate this?
Question 8: Name three (3) differentials for Ms. Jones’ initial presentation.
Question 9: What patient education would you give Ms. Jones and her daughter? What would be your follow-up instructions?
Question 10: Would amoxicillin/clavulanate plus a macrolide have been an option to treat Ms. Jones’ Pneumonia? Explain why or why not.
Response Amanda,
When a patient is dealing with a diagnosis of multiple myeloma, it is important to them to, of course, maintain a normal life pattern. According to Nightingale College (2022), Therapeutic communication in nursing consists of an exchange between patient and nurse using verbal and nonverbal cues. This allows the patients to understand better their condition and how to proceed with quality of life. It’s also important to educate them that time will give the patient the strength they need to get there. Over the weekend, I recently had a patient who has been dealing with PAD to her right foot for several years and came in for a Femoral Popliteal Bypass. This patient was independent prior and very strong-willed. Unfortunately, after three surgeries within one week, she was not able to obtain blood flow to her right foot and has been in excruciating pain.
It isn’t easy to go from being so independent, carrying on with your daily living, to relying on others for help. She felt embarrassed to ask for help to get up to use the restroom because she couldn’t bear the weight on her right foot. She was tearful for most of my shifts with her; she fired every nurse before me. When you get the chance to sit with your patients and be honest, listen to them, and understand their frustration, because we are all human, you get to know them more profoundly and can advocate better for them. I built her trust and supported her to regain some normality. I saw the hopelessness in her husband as he wanted her to get a BKA to “end the pain.” The right pain management was vital; it may not take it away entirely, but it will allow her to function as normally as she could until she decides what was right for her if she wanted to do a BKA or go home and allow time to heal and recover. You want the patient to feel free to express their ideas or feelings regarding their own care and accept what’s to come.
Educating the husband on making sure he took care of himself while his wife was in the hospital, reminding him that it was okay for him to leave, go home, get fresh air, and go to work so that he could arrange for whatever necessities he needed to for when she was ready for a safe discharge. When the family sees the care their loved ones are receiving, they would feel comfortable leaving the bedside, so it truly starts with the nurse and the patient; that first impression lasts a lifetime. Bedside manners are essential when dealing with ill patients, especially with the actively involved families.
Palliative care is an excellent resource for families, just as much for patients who are critically ill. It’s a service that can be provided in a hospital or the privacy of your own home. This will give families the support they need during a difficult time (National Institute on Aging, 2022).
References
National Institute on Aging (2021). What are Palliative care and Hospice Care? https://www.nia.nih.gov/health/what-are-palliative-care-and-hospice-careLinks to an external site.
Nightingale College (2022). Therapeutic Communication Techniques: How Good Nurses Can Provide Better Patient Care for Best Results. Retrieved from: https://nightingale.edu/blog/therapeutic-communication.htmlLinks to an external site.
Week 8 Case Study
CC: Mrs. Derrick is a 78-year-old female who comes to the office with complaints of increasing symptoms of lethargy; fever, night sweats, a 15 lb. weight loss over 6 months; bleeding gums when she brushes her teeth; purplish patches in the skin; and shortness of breath.
HPI:
She states that she has had a sensation of deep pain in her bones and joints.
She notes that her employment history includes working at a dry-cleaning shop for 15 years, with an exposure to dry cleaning chemicals (benzenes are known to be a possible cause of leukemias)
PE shows enlarged lymph nodes and swelling or discomfort in the abdomen.
You diagnose this patient with acute lymphoblastic leukemia (ALL).
Address the following in your SOAP note:
What additional history about her past work environment would you explore?
What additional objective data will you be assessing for?
What tests will you order? Describe at least four lab tests.
What are the differential diagnoses that you are considering? Describe two.
List at least two diagnostic tests you will order to confirm the diagnosis of ALL.
Will you be looking for a consultation? Please explain.
As the primary care provider for this patient with ALL:
Describe the education and follow-up you will provide to this patient during and after treatment by the hematologist-oncologist.
Describe at least three (3) roles as the PCP for the ongoing care of the ALL patient.
