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• Karina Rodriguez

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C DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) ▪ Pneumonia ​- An acute infection of the lung parenchyma that impairs gas exchange and may be caused by multiple microorganisms, including

mycobacteria, bacteria, viruses, protozoa and fungi.

- ​Pathophysiology:​ An organism enters the upper airway and multiplies in the epithelium, then it spreads to the lungs via secretions or the blood. Next, a gel-like substance forms as microorganisms which causes phagocytic cells to break down. This substance builds up within the lower airway structure and Inflammation occurs, which involves the alveoli, alveolar ducts, and interstitial spaces surrounding the alveolar walls. ●

Influenza - ​A viral infection that attacks your respiratory system such as the lungs, nose, and throat. -

Pathophysiology: ​Influenza is an acute disease that targets the upper respiratory tract and causes inflammation of the upper respiratory tree and trachea. The acute symptoms persist for 7 to 10 days and the disease is self-limited in most healthy individuals. The immune reaction to the viral infection and the interferon response are responsible for the viral syndrome that includes high fever, coughing and body aches. The virus replicates in the upper and lower respiratory passages starting from the time of inoculation and usually peaking after 48 hours. DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS)

▪ Complete Blood Count ​- This test measures for blood cell count including white blood cells, platelets, hemoglobin and hematocrit. Since this pt. has pneumonia and hypertension, it is critical to monitor her blood levels, specifically her blood’s oxygen levels and her white blood cell count. A ​CBC with differential may reveal an infection as well as a decrease in Hb since oxygen saturation levels tend to be low in pneumonia pts. ​The pts. Hb was 12.1 which is on the lower side but within normal range and her WBC count was at 18,000 which is high and further validates her diagnosis of influenza viral infection 10 days prior to developing pneumonia. ▪ Electrolyte Levels - ​This test measures for any fluid or electrolyte imbalances in the body, such as potassium, calcium & sodium levels. Since this pt. is currently diagnosed with pneumonia, it is best to monitor the pts. electrolyte levels to ensure there are no abnormal values or imbalances, especially with her PCO2 & PO2 levels due to pneumonia causing impaired oxygen flow. The pts. electrolytes were all within normal limits except for her creatinine level which was 0.76 and which is considered to be low. ▪ Arterial Blood Gas Panel- ​This test measures ​the amounts of arterial gases, such as oxygen, carbon dioxide, bicarbonate and pH levels and gives a huge indicator to any impaired or abnormal gas exchanges that are occurring. ​Due to the pts. pneumonia diagnosis, this pt. is at risk for experiencing impaired gas exchange between her carbon dioxide and oxygen levels. The pts. pH was 7.3 indicating acidosis, PCO2 was 58 which is high, PO2 was 72 which is low and indicates low oxygen levels being exchanged and her oxygen saturation was at 94% meaning her oxygen levels in the blood were low. This combination of abnormal results has concluded that the pt. is experiencing respiratory acidosis. ▪ ​Chest X-Ray - ​This type of imaging is useful for showing how severe the pts. lungs are impacted by pneumonia by looking at the alveoli and identifying any mucus blockages by using electromagnetic waves. Locating where & knowing how severe the pneumonia is can help plan & personalize the pts. type of care. Upon admission, this pt. had an x-ray that resulted in the diagnosis of having pneumonia with infiltration in the right lower lung lobe. ▪ Sputum Culture​ - ​A test that checks for bacteria or another type of organism that may be causing an infection in your lungs or the airways leading to the lungs. The pts. sputum was assessed and appeared as a rust color, which is a sign of a bacterial infection.

PATIENT INFORMATION M.H. is a 72 yr. old hispanic female who is a retired school teacher, married & has been diagnosed with pneumonia in the right lower lobe of the lung. M.H. currently lives at home with her husband. M.H. was diagnosed with influenza 10 days before admission and was started on antibiotics after a sputum specimen was obtained. The pt. has been experiencing fever, malaise, SOB and a persistent cough and reports feeling worse during activity. The pt. is also diagnosed with hypertension and is considered to be overweight with a BMI of 28.6. She is a current smoker and reports smoking a half-a-pack a day for 52 years and shows no desire to quit. Her advanced age and history of smoking puts her at a higher risk of developing hypoxemia, asthma or experiencing respiratory failure.

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​ANTICIPATED PHYSICAL FINDINGS Abnormal ABG labs showing impaired gas exchange Decreased oxygen saturation level Diaphoresis Increased HR Increased RR Knowledge Deficits on pneumonia Dry mucous membranes Adventitious lung sounds focused on the right lower lung lobe. Impaired respiratory function ANTICIPATED NURSING INTERVENTIONS

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Perform a complete Neurological Assessment to determine LOC and level of sensory functions. Assess skin turgor and signs of dehydration every 2 hours. Perform a complete Respiratory Assessment to monitor for any abnormal or adventitious breath sounds. Perform a Pain Assessment every 4 hours to determine level of pain before and after medications have been given. Monitor vital signs (BP, Oxygen, Pulse, Temperature) every 4 hours. Monitor I&O and assess for amount, color and frequency of urine/stool. Educate pt. on coughing and oxygen therapy. Educate pt. on how to use an incentive spirometer and have pt. use the spirometer 10x every hour Monitor ABG labs to identify any abnormalities and report any changes to HCP. Apply cold therapy to reduce symptoms of fever and diaphoresis. Administer antibiotics to relieve symptoms of infection.

vSim ISBAR ACTIVITY INTRODUCTION

STUDENT WORKSHEET My name is Karina Rodriguez and I am a Registered Nurse. I currently work at the Community Hospital​. I am calling about Mona Hernandez in room 124.

Your name, posi​ti​on (RN), unit you are working on She is an 72-yr-old hispanic female who was admitted into this hospital yesterday afternoon by her primary doctor due to having pneumonia. The pt. has been experiencing a dry cough, fever and Pa​ti​ent’s name, age, specific reason for flushed skin. The pt. reports having sharp pain when coughing and initiating movement. visit SITUATION

BACKGROUND Pa​ti​ent’s primary diagnosis, date of admission, current orders for pa​ti​ent

ASSESSMENT Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs

RECOMMENDATION Any orders or recommendations you may have for this patient

The pt. was admitted yesterday afternoon on 10/28/2020 at 1338. The pts. primary diagnosis is pneumonia. A chest x-ray was ordered upon admission & showed infiltrates in right lower lobe. Pt. is also hypertensive. She is a current smoker and reports that she has smoked a half-a-pack a day for 52 years and shows a low desire to quit. She reports drinking 1-3 drinks a week. She reports to have been taking a hypertensive medication & has acetaminophen 650 mg PO q6hrs & guaifenesin 100 mg PO q4hrs ordered as PRN for pain. She is also on hydrochlorathiazide 25 mg PO as an antihypertensive & heparin 5000 units subq as an anticoagulant. She also has 400mg moxifloxacin IVPB scheduled every 24hrs. Pts. vital signs were taken at 1605. BP is 134/80 & was taken on the left upper arm, HR is high at 110 bpm, temp. is also high at 101F & RR is at 21 breath/min with reduced breath sounds heard at the right lung base with no adventitious sounds. Pedal pulse is strong at 110 bpm. Capillary refill is less than 2 secs. Pt. is oriented x3 & has no known allergies. Pts. labs were assessed & her ABG levels were abnormal & WBC count was high. Pt. pH was low at 7.3, HCO3 is 22, PCO2 high at 58, PO2 low at 72 & O2 saturation low at 88. Pts. pain level was assessed at 1612 & reported a pain level of 1 out of 10 & described feeling a sharp pain when coughing or moving. Pt. reports having SOB. Pt. was put on nasal cannula 3L/min at 1615 & has maintained an O2 level of 94%. Pt. used incentive spirometer at 1617. Pt. had a dry persistent cough & a sputum was obtained that appeared rust colored. ​Her WBC count was high at 18,000. She was repositioned at 1620 to high fowler’s to accommodate airway clearance. Her skin appears flushed, warm & sweaty. ​Mucous membranes showed cyanosis, but no signs of dehydration. IV site is clean, dry & intact. The pt. should remain on nasal cannula to maintain O2 level of 94%. Pt. CBC & ABG labs should be monitored hourly to report any abnormal changes. The pt. should use incentive spirometer 10x per hour to promote adequate exhalation & inhalation. A respiratory assessment should be performed every 2 hours & report any adventitious sounds or change in respiratory functions. Head-to-toe assessment should be performed to assess skin integrity every 2 hrs. Pt. Pt. pain should be reassessed every 4 hrs. Pt. should be kept hydrated & have cold therapy applied to lower fever. Pt. should be educated on the disease process of pneumonia, deep breathing & coughing exercises. Pt. should remain in high fowlers position.

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Hydrochlorothiazide 25 mg PO daily CLASSIFICATION: Therapeutic: antihypertensive, diuretics Pharmacologic: thiazide diuretics PROTOTYPE: Diuretics SAFE DOSE OR DOSE RANGE, SAFE ROUTE For adults, the safe range & route is 12.5-100 mg/day PO in 1-2 divided doses (up to 200 mg/day). Daily doses above 25 mg are associated w/ greater likelihood of electrolyte abnormalities. ​25 mg PO daily is considered to be a safe dose & route. PURPOSE FOR TAKING THIS MEDICATION ▪ Management of mild to moderate hypertension.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION ▪ Instruct pt. to take this medication at the same time each day. Take a missed dose as soon as remembered but not just before the next dose is due. Do not double dose. ▪ Caution pt. to change positions slowly to minimize orthostatic hypotension. ▪ Advise pt. to report rash, muscle weakness, cramps, nausea, vomiting, diarrhea or dizziness to HCP. ▪ Advise pts. to continue taking medication even if feeling better. Medication controls, but does not treat hypertension. ▪ Encourage pt. to comply with additional interventions for hypertension such as weight reduction, low-sodium diet, regular exercise, smoking cessation & moderation of alcohol consumption. ▪ Instruct pt. & family in correct technique for monitoring weekly BP. ▪ Emphasize the importance of routine follow-up exams.

Resource: Davis’s Drug Guide

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Heparin 5000 units Subcutaneous q12h CLASSIFICATION: Therapeutic: anticoagulants Pharmacologic: antithrombotics PROTOTYPE: Anticoagulants SAFE DOSE OR DOSE RANGE, SAFE ROUTE For adults, the safe range & route is 5000 units IV every 8 hrs Subcut. ​5000 units Subcut q12h is considered to be a safe route & dose for this pt. PURPOSE FOR TAKING THIS MEDICATION ▪

Prophylaxis & treatment of various thromboembolic disorders, such as VTE, pulmonary emboli, atrial fibrillation w/ embolization & peripheral arterial thromboembolism.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION ▪ Advise pt. to report any symptoms of unusual bleeding or bruising to HCP immediately. ▪ Instruct pt. not to take medications containing aspirin or NSAIDs while on heparin therapy. ▪ Caution pt. to avoid IM injections & activities leading up to injury & to use a soft toothbrush & electric razor during heparin therapy.

Resource: Davis’s Drug Guide

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Moxifloxacin 400 mg IVPB infusion daily CLASSIFICATION: Therapeutic: anti-infectives Pharmacologic: fluoroquinolones PROTOTYPE: Anti-infectives SAFE DOSE OR DOSE RANGE, SAFE ROUTE For adults, the safe dose & route for pneumonia pts is 400 mg PO/IV daily x10-14 days​.​ ​400 mg IVPB infusion daily is a safe dose & route for this pt. PURPOSE FOR TAKING THIS MEDICATION ▪

Treatment of the following bacterial infections: Respiratory tract infections, acute sinusitis, acute exacerbations of chronic bronchitis & community acquired pneumonia (CAP).

PATIENT EDUCATION WHILE TAKING THIS MEDICATION ▪

Instruct pt. to take medication as directed at evenly spaced times & to finish medication completely, even if feeling better. Take missed doses as soon as possible, unless almost time for the next dose. Do not double dose. Advise pt. that sharing of this medication may be dangerous.

▪ Encourage pt. to maintain a fluid intake of at least 1500–2000 mL/day to prevent crystalluria. ▪ May cause dizziness and drowsiness. Caution pt. to avoid driving or other activities requiring alertness until response to medication is known. ▪ Advise pt. to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools). ▪ Instruct pt. to notify HCP immediately if pt. develops a rash, jaundice, sign of hypersensitivity or tendon pain, swelling or inflammation occurs. If

tendon symptoms occur, avoid exercise and use of the affected area. ▪ Instruct pt. to notify HCP if fever & diarrhea develop.

Resource: Davis’s Drug Guide

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Guaifenesin elixir 650 mg PO q6h PRN for cough CLASSIFICATION: Therapeutic: allergy, cold & cough remedies expectorant PROTOTYPE: Cough remedies SAFE DOSE OR DOSE RANGE, SAFE ROUTE For adults, the safe dose & route is ​200–400 mg every 4 hr PO or 600–1200 mg every 12 hr PO as extended-release product (not to exceed 2400 mg/day). Since the HCP prescribed this medication as a PRN, 650 mg PO q6h is considered to be a safe dose & route for this pt. PURPOSE FOR TAKING THIS MEDICATION ▪ Reduces viscosity of tenacious secretions by increasing respiratory tract fluid. ▪ Mobilization & subsequent expectoration of mucus.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION ▪

Instruct pt. to cough effectively. Pt. should sit upright & take several deep breaths before attempting to cough.

▪ Advise pt. that this medication is a drug with known abuse potential. Protect it from theft & never give to anyone other than the individual for whom it was recommended. Store out of sight and reach of children & in a location not accessible by others. ▪ Inform pt. that drug may occasionally cause dizziness. Avoid driving or other activities requiring alertness until response to medication is known. ▪ Advise pt. to limit talking, stop smoking, maintain moisture in environmental air & take some sugarless gum or hard candy to help alleviate the discomfort caused by a chronic nonproductive cough. ▪ Instruct pt. to contact HCP if cough persists longer than 1 week or is accompanied by fever, rash, or persistent headache & sore throat.

Resource: Davis’s Drug Guide

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Acetaminophen 650 mg PO q6h PRN for pain CLASSIFICATION: Therapeutic: antipyretics, nonopioid analgesics PROTOTYPE: Antipyretics SAFE DOSE OR DOSE RANGE, SAFE ROUTE For adults, the safe range & route is 325-650 mg every 6 hr or 1g 3-4x daily or 1300mg every 8 hr. ​650 mg PO q6h PRN is considered to be a safe dose & route. PURPOSE FOR TAKING THIS MEDICATION ▪ Treatment of mild pain & fever.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION ▪ Advise pt. to take medication exactly as directed & not to take more than recommended amount. Chronic excessive use of greater than 4g per day may lead to hepatotoxicity, renal or cardiac damage. ▪

Advise pt. to avoid alcohol (3 or more glasses per day increases the risk of liver damage) if taking more than an occasional 1-2 doses & to avoid taking concurrently with salicylates or NSAIDs.

▪ Advise pt. to discontinue acetaminophen & notify HCP if rash occurs.

Resource: Davis’s Drug Guide

Date:​ 10/29/20​ Initials: M.H.

Student Name: ​Karina Rodriguez

Diagnosis: Pneumonia Hypertension Influenza

Age: M/F: Length of Stay: ​1.7 days

F Code Status: Full Code

Allergies: N/A

HCP:

Jacob Jones Consults: no current consults indicated on order

Isolation: Standard Precautions

IV Type: N/A

Assigned vSim: ​ Mona Hernandez

Critical Labs: ABGs: pH - 7.3 (low) PCO2 - 58 (high) Fall Risk: ​Morse Fall Risk Location: Score: 15 (Low Risk) PO2 - 72 (low) Accessory Cephalic Vein SaO2 - 94% (low) CBC Panel: Transfer: ​Pt. reports WBC - 18,000 (high) Fluid/Rate:​ N/A Electrolytes: weakness & fatigue, but does not need assistance in Creatinine - 0.76 (low) transferring/ambulating. Coagulation Test Sputum Culture/Gram stain

Other Services: Dietician/Nutritionist

Consults Needed: Respiratory Therapist Smoking Cessation Program Exercise Program

Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: ​Pt. has been admitted by her primary care physician due to having influenza for 10 days prior to admission. Pt. had a chest x-ray consult upon admission & was diagnosed with pneumonia with infiltrates in the right lower lobe. Health History/Comorbities (that relate to this hospitalization): ​Pt. is currently diagnosed with pneumonia & hypertension. The pt. has had influenza 10 days ago prior to admission. Pt. has persistent dry cough and fever of 101F & poor oxygenation (lower than 94%). The pt. has poor appetite & has a BMI of 28.6 which is considered overweight.. All immunizations are up to date. Pt. is a current smoker & reports smoking ½ a pack a day for the past 52 yrs. Pt. reports drinking 1-3 drinks per week. Pt. has not reported any information on exercising. Shift Goals/ Patient Education Needs: 1. ​Pt. will have a respiratory rate of 20 or below prior to the end of the shift. 2. ​Pt. will use an incentive spirometer 10x every hour to prevent alveoli collapse & improve respiratory function. 3. ​Pt. will retain a PCO2 level between 35 & 45 and PO2 level of 79 or greater prior to the end of the shift. 4. ​Pt. will be educated on coughing, deep breathing exercises & oxygen therapy to learn how to expel mucus and clear airways. 5. ​Pt. will be on nasal cannula 3 L/min throughout the shift to maintain O2 saturation level of 94% or greater. Path to Discharge: Pt. will be seen by a respiratory therapist prior to discharge to encourage deep breathing, provide oxygen therapy & promote coughing. Pt. will be discharged home with no signs or symptoms of infection & given the proper antibiotic prescription by HCP. Pt. & caregiver will be educated on the disease process of pneumonia & its risk factors. Path to Death or Injury: Pt. & caregiver will be educated on oxygen therapy. Pt. will be educated on deep breathing exercises and its benefits towards respiratory function. Pt. will be educated on how to use an incentive spirometer by hospital protocol and its benefits towards respiratory function. Pt. will be educated on standard precautions & infection control protocol via hospital policy. Nurse will actively practice standard precautions & maintain hand hygiene. Pt. will be educated on antibiotic medications and management of pneumonia symptoms.

Alerts: What are you on ​alert ​for with this patient? (Signs & Symptoms) 1. ​ Change of LOC or mental state related to developing infection. 2. ​ Change of respiratory rate of 20 breaths/min or higher or 12 breaths/min or lower 3​.​ ​Having O2 saturation fall below 92%. 4.​ Abnormal shift of ABG & CBC lab values, especially in pH, PCO2, HCO3 & PO2 levels. 5.​ Increased temperature higher than 101.4F 6. ​Change in skin integrity due to warm and sweaty skin. 7.​ Pt. reporting chest pain level of 6 or higher.

What ​Assessments ​will focus on for this patient? (How will I identify the above signs & symptoms?) 1.​ Neurological Assessment to assess LOC & detect any changes in mental state. 2. ​Inspection of skin integrity every 2 hours to assess change in edema, color & temperature of skin. 3. ​Respiratory Assessment every 2 hours to assess respiratory rate & lung sounds. ​4.​ Perform vital signs assessment every 4 hours with emphasis on cardiac and respiratory vitals. ​5. ​Perform a pain assessment every 4 hours. List ​Complications ​may occur related to dx, procedure, comorbidities:

​Management of Care: What needs to be done for this Patient Today? 1. ​Assess & monitor vital signs every 4 hrs. 2. ​Perform a respiratory assessment every 2 hours & document any abnormal changes. 3. ​Meet w/ respiratory therapist to discuss oxygen therapy & deep breathing exercises. 4. ​Perform a head-to-toe assessment to assess skin integrity and turgor. 5. ​ Educate pt. on how to use an incentive spirometer. 6. ​Apply cold therapy to lower fever. 7. ​Assess neurological status for any signs of confusion. Priorities for Managing the Patient’s Care Today 1. ​ Pt. will have lungs auscultated every 2 hours to monitor for change of RR or adventitious breath sounds. 2. ​Pt. will use incentive spirometer 10x every hour to improve deep breathing. 3. ​Pt. will have vital signs taken every 4 hours to monitor for any abnormal findings. 4. ​Pt. will be encouraged to eat & given fluids to stay hydrated. 5.​ Pt. will have nasal cannula 3 L/min applied throughout the shift. 6. ​Pt. will have a cardiac assessment performed every 2 hours to monitor HR & BP. 7. ​Pt. will have cold therapy applied to reduce symptoms of fever. 8.​ Assess pt. pain level every 4 hours What aspects of the patient care can be Delegated and who can do it?

1. ​ Pt. may develop resistance to antibiotics prescribed.

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2. ​Pt. may go into respiratory failure if pneumonia is not properly treated.

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3. ​Pt. skin integrity may be compromised due to fever, warmth & diaphoresis of epidermis. 4.​ Pt. may go into cardiac arrest if HR & BP remain elevated.

Taking vital signs periodically & retrieving lab values from the lab for the patient can be delegated to a UAP & LPN. Recording & collecting I&O information can be delegated to a UAP & LPN. Applying cold therapy to pt. can be delegated to an LPN. Providing fluids and food for the pt. can be delegated to a UAP & LPN.

What nursing or medical ​interventions ​may ​prevent ​the above Alert or complications? 1. ​RN will perform a respiratory assessment every 2 hrs to monitor for adventitious breath sounds or abnormal changes in respiratory rate & CO2 levels. 2. ​RN will perform head-to-toe assessment & assess skin integrity to prevent pressure injury formation and monitor for signs of dehydration. 3. ​RN will have pt. use incentive spirometer 10x every hour to improve deep breathing and lung expansion. 4. ​RN will monitor ABG, CBC & Electrolyte values for increased signs of infection, impaired gas exchange or changes in O2 levels. 5​. RN will provide cold therapy to diminish pyrexia in pt. 6.​ RN will keep pt. hydrated by providing fluids and preventing dehydration. 7. ​RN will keep pt. on nasal cannula 3 L/min to maintain O2 saturation levels at 94% or greater.