Case study ~ UNIT 2
Part I: Initial Nursing Assessment
Jackie Frost is a 74-year old male to female (transgender) with a past medical history of benign prostatic hyperplasia (BPH), Multiple Myeloma (currently in remission), Myasthenia Gravis. She was prescribed a 5-day course of dexamethasone and a Salbutamol inhaler by her family physician for respiratory support as she was experiencing shortness of breath after she tested positive for COVID-19. Mrs. Frost is triple vaccinated, last dose December. 2021
Jackie presents to the emergency department today with increasing shortness of breath, fatigue, poor PO intake, fever and chills on and off for the past week. Patient is mouth breathing, nasal flaring and speaking only 1-2 words at a time, and has rapid shallow breathing. Jackie has a productive weak cough with yellow/white phlegm sputum. On initial vital signs: BP 89/52, HR: 109/min, RR 32/min, T 37.4, SpO2 85% on Room air. Patient expressed that she feels like she cannot catch her breath.
Personal/Social History:
Jackie is retired and lives at home with her husband. Her two adult children live out of province. She has recently attended a wedding and has been exposed to COVID-19. One week after being exposed, the PCR test came back positive. She is active in her community and has a membership at the community golf course. Since she has been dealing with changes in her health and is currently in remission, she has been healthy and tried to avoid big events as Jackie is immunocompromised. She expresses to you that she currently should have stayed home and is feeling guilty and frustrated that she even went to the wedding. No history of alcohol, smoking, or drug abuse.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
RELEVANT Data from Social History: Clinical Significance:
Jackie is transferred to the ED and quickly brought to a room. You introduce yourself, and collect the following clinical data:
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 37.9 C (Temporal) Provoking/Palliative: Denies
P: 105/min Quality: Denies
R: 33/min Region/Radiation: Denies chest pain
BP: 82/48 (MAP =59) Severity: 0/10
O2 sat: 85% room air Timing: N/A
Current Assessment:
GENERAL SURVEY: Appears tired and in mild distress from trying to catch breath. Her husband reports that her appetite has decreased over the past week.
NEUROLOGICAL: Alert & oriented to person, place, time (x3); muscle strength 5/5 in both upper and lower extremities bilaterally.
HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally. Lips dry and oral mucosa sticky.
RESPIRATORY: Breath sounds clear to upper lobes, diminished bilaterally with course crackles to both bases. Moderate & labored work of breathing on room air. Persistent weak productive cough with sputum.
CARDIAC: Pale. Heart sounds regular S1, S2 and tachycardic, pulses weak on palpation at radial/pedal landmarks, cap refill 4-5 seconds. No JVD noted at 30-45 degrees.
ABDOMEN: Abdomen round, soft, and non-tender. BS + in all 4 quadrants.
GU: Voiding frequently with urgency, urine clear/yellow-amber colored
INTEGUMENTARY: Skin warm, dry, intact. No clubbing of nails. Skin integrity intact, no tenting present.
What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Assessment based off priority***)
RELEVANT Assessment Data: Clinical Significance:
Clinical Judgement:
1) What priority diagnostic/laboratory tests would you think the MRHP would order and why? (Only list 2 that stand out and take priority)
2) Which system is your focus assessment?
What nursing interventions should you provide first based off of your initial assessment?
3) The MRHP orders a 1L bolus STAT to be given as fast as possible. Which IV solution do you think will be ordered (Hypotonic, Isotonic, Hypertonic) Provide rationale.
Part II: Interpreting Diagnostic Data:
The primary care provider orders the following diagnostic tests: chest x-ray & ABG
Chest X-Ray Report reads:
Findings: The Cardiomediastinal silhouette and pulmonary vasculature are within normal limits and in size. The lungs show no signs of pneumothorax. Trachea unremarkable.
-Mild/moderate right/left pleural effusion seen on image
-Consolidation present on both right and left side (Right lower lobe > left)
Radiology: Chest X-ray
Results: Clinical Significance:
Right lower lobe pneumonia with pulmonary edema -Accumulation of fluid in the extravascular spaces of the lung. Confirms the presence of pulmonary edema that may be the cause of respiratory issues and poor tissue perfusion.
Right Lower Lobe pneumonia: Is characterized by inflammatory exudate within the intra-alveolar space resulting in consolidation that effects a large continuous area of the lobe of a lung.
Complications: respiratory and metabolic acidosis, respiratory failure, cardiac or respiratory arrest
S&S: decreased SpO2 sats, productive cough, course crackles, tachycardia, poor perfusion, hypotension
Complete Blood Count (CBC)
WBC HGB PLTs
% Neuts
Bands
Current: 3.4 133 150 2.3 0
RELEVANT Lab(s): Clinical Significance: TREND: Low/High/WNL
WBC (4.5 – 11)
Hgb (120 – 160)
PLTs (150 – 400)
% Neuts(2.9 – 9.0)
Band (0 – 6%)
Basic Metabolic Panel (BMP)
Na (135—145 mEq/L) K (3.5—5.0 mEq/L) Glucose Creat. (0.6—1.2 mg/dL)
Current: 146 4.0 5.5 0.96
Which lab values are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:
The doctor orders a STAT Arterial Blood Gas (ABG):
1) As the bedside nurse who would you communicate with to ensure that the appropriate member of the multidisciplinary team is notified?
2) Which discipline completes the ABG test?
3) Why is an ABG performed?
ABG Results: What does this indicate
Lab Normal Range Results
pH 7.35—7.45 7.47
HCO3 22—26 17
PaCO2 35—45 32
O2 Saturation 92—100% 86%
Part III: Put it All Together to Think Like a Nurse
1. Interpreting all clinical data collected, what is the patient’s diagnosis?
2. What response system(lines of defense) do you think has been activated initially?
3. In your OWN words explain the pathophysiology of of the priority problem.
4. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (fill in the table below)
Nursing PRIORITY:
GOAL of Care:
Nursing Interventions: Rationale: Expected Outcome:
5. Provide rationale and expected outcomes on the following care provider orders
Care Provider Orders: Rationale: Expected Outcome:
Establish peripheral IV
Blood culture
IV Maintenance fluids 0.9% NaCL at 75cc/hr
Urine Analysis/Culture
Ceftriaxone IV 1 g every 12 hrs. over 30 minutes (due at 0800 as per MAR)
Vancomycin IV 1 g. every 12 hrs. over 60 minutes (Due at 0900)
Vitamin D 1000 i/units
Prednisone 50mg daily
Pantoprazole 40mg daily
Tamsulosin 0.4mg daily
Estrogen 8 mg daily
For the following six drugs: provide a classification of the each of the drugs and the mechanism of action.
Medication Classification Mechanism of Action
Ceftriaxone IV 1 g every 12 hrs.
Vancomycin IV 1 g. every 12
Vitamin D 1000 i/units
Prednisone 50mg daily
Pantoprazole 40mg daily
Tamsulosin 0.4mg daily
Estrogen 8 mg daily
Art of Nursing
Clinical Scenario:
Before you left for your breakfast break Mrs. Frost’s oxygen was set at 5L via nasal prongs, RR 26/min, SpO2 93%, BP 105/65. You return from break and your patients oxygen saturations are <90% and starting to drop. The patient can only speak one word at a time, nasal flaring and suprasternal and subcostal indrawing present, respirations are shallow and rapid. You get a saturation reading of 82%.
The patient asks you to phone and update her husband . She asks you “I am going to die”?
How do you respond to this and who do you notify as your patient is actively deteriorating…
Did you know? Transgender individuals may delay seeking healthcare when ill due to financial costs, fear of discrimination, or previous negative experiences within the healthcare system. According to Lambda Legal, transgender adults experience significantly higher rates of healthcare providers being unaware of their health needs, refusing to provide care, providing substandard care, or treating them poorly during provision of care than lesbian, gay, and bisexual adults.
Fill in the description to the following definitions:
• Transgender:
• Transwoman:
• Transman:
• Genderqueer and gender nonconforming:
• Cisgender:
• Sex assigned at birth:
• Gender:
• Gender expression:
• Gender identity:
• Sexual orientation:
• Gender transition:
• Coming out:
Nursing Considerations
Name five considerations you can do as a nurse to create a welcoming environment for transgender patients.
