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Jimmy Bley Case Study #2

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Erika Bade

on 4 February 2015

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Transcript of Jimmy Bley Case Study #2

Pharmacological Treatments
1. Mucolytics: given to break up sputum.
2. Expectorants: given to break up sputum.
3. Bronchodialators: given to open up airway.
4. Analgesic: given to improve cough by decreasing discomfort.
5. Antipyretic: reduce fever.
6. Antimicrobial: kill bacteria.
Altered Tissue Integrity r/t puncture of integument by foreign object as evidenced by wound on lower left leg
Jimmy Bley's Health History
New Diagnosis: Impaired Gas Exchange
Pneumonia is an infection in the lungs caused by inhaled bacteria. This causes pathogens, fluid and cellular debris to fill the alveoli, inflaming the lungs and making it difficult to breathe.
Emphysema predisposes Jimmy to pneumonia.
Expected Assessment Findings
Case Study #2
Jimmy Bley
Jimmy Bley
What happened?
78 year old Native American male with a history of COPD. His efforts to quit smoking have been unsuccessful so far and seems unaware of the severity of his condition.
Jimmy's left shin was stabbed by a large branch while mowing the lawn leaving him with an open wound, which put him at high risk for infection.
Altered Tissue Integrity r/t puncture of integument by foreign object as evidenced by wound on lower left leg

Impaired Gas Exchange r/t decreased functional lung tissue as evidenced by right lower lobe pneumonia
New Nursing Diagnoses:
Chronic Obstructive Pulmonary Disease
Insufficient Nutrition r/t lack of balanced diet. AEB
Patient statement of eating few fruits and vegetables
Ineffective Self-Health Management r/t decisional conflicts, lack of expressed interest in improving health behaviors, and knowledge deficit AEB
Pt. denial of serious health concerns
Inadequate use of medications and aid devices
Patient's continuation of smoking habits
Activity Intolerance r/t imbalance between oxygen supply/demand AEB
Verbal report of fatigue
Exertional dyspnea following walking and mowing lawn.
Impaired Gas Exchange r/t decreased functional lung tissue AEB
Right lower lobe pneumonia
Altered Tissue Integrity r/t puncture of integument by foreign object AEB:
wound on left lower leg
New Diagnosis: Altered Tissue Integrity
NOC #1
NOC #2
NOC #3
Impaired gas exchange r/t decreased functional lung tissue AEB right lower lobe pneumonia
Verbalize understanding of oxygen supplementation and other therapeutic interventions after 24 hrs.
Demonstrate improved ventilation and adequate oxygenation AEB blood gas levels within normal limits for Jimmy after 3 days
More Works Cited
Works Cited
Productive cough, possible yellow/green sputum, tachypnea, possible dyspnea, chills, stressed/anxious facial expressions, increased respiratory rate
Fever, increased tactile fremitus on right lower lobe (COPD barrel chest may affect detection), decreased chest expansion on right side (may not be recognizable with barrel chest)
Client will experience decrease in pain level to an established tolerable level within the next four hours

Main concern: what will make it easiest for Jimmy to follow through and regularly care for himself?

Speak loudly, clearly, and respectfully, respect Native American practices
Educate in a quiet, private location
Explore why he has not used the education provided to him before to protect his health (without using judgemental questions, sounding disapproving, etc.)
Emphasize the seriousness of his recent and long-term illnesses - i.e. point out that his recent acquisition of pneumonia can further his activity intolerance and create risk for even more serious health concerns in the future. Set goals for him to achieve.
With Jimmy's permission, invite wife Cecilia to join the discussion and help think of ways to make care easiest and least disruptive to Jimmy's daily life.
give demonstration for complicated procedures and provide pamphlets with reminders on how to carry them out
document what was taught and how,
In order to evaluate teaching success- have Jimmy restate and repeat his in- home care, what medications he should be taking, what activities he should be avoiding, and key signs of further illness/ infection.
Obtain list of patient's current and past medication use, as well as information about any drug reactions
American Lung Association (n.d.). Pneumonia - American Lung Association. Retrieved June 5, 2013, from http://www.lung.org/lung-disease/pneumonia/
Describe to patient and wife the regimen of medications suggested or prescribed by physician
Educate patient on non-pharmacological methods of controlling pain (imagery, distraction, relaxation, etc)
Bronchophony, egophony, whispered pectoriloquy, bronchial breath sounds and crackles (may be muffled due to COPD)
Client will verbalize understanding of procedure for, and importance of daily cleaning and care for wound within 24 hrs.
Educate patient on cleaning and wrapping techniques for his wound
Educate patient about his risk for, symptoms of and consequences of infection
Monitor wound for drainage, color, and changes
Client's wound will decrease to half of its current size within two weeks without signs of infection
Help patient to create a calendar for cleaning and caring for his wound, along with taking his other medications
Involve Jimmy's wife, Cecilia, in his care plan: make sure she knows and understands how to clean and wrap his wound and is familiar with the calendar
Maintain circulation throughout the lower limbs, thus preventing blood clots and further risk for infection
Maintain "normal" lung fields for Jimmy, and remain free of additional signs of respiratory distress after 1 month
Ausculate breath sounds for additional crackles and wheezes not r/t COPD
Educate Jimmy on the importance of not smoking, and receiving the pneumococcal vaccine
Provide Jimmy with a written action plan for his care in addition to verbal information
Provide one-on-one educational sessions to create a collaborative learning experience
Include his family and wife in educational sessions to increase support at home
Use pulse oximeter to measure blood oxygen levels
Implement use of nasal cannula
Educate Jimmy on use and benefits of oxygen supplementation
Monitor effects of analgesics used for Jimmy's leg injury on his respiratory pattern
D'Amico, D., & Barbarito, C. (2012). Health & physical assessment in nursing. (2nd ed.). Pearson Education, Inc.
Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook an evidence-based guide to planning care. (9th ed.). St. Louis,Missouri: Mosby Elsevier.
NOC #1
NOC #2
NOC #3
Pneumonia in Detail
Healthy Person: Alveolar macrophages can destroy bacteria without triggering immune response.
Pneumonia: Bacteria are especially resistant or high in population. Causes macrophages to become overwhelmed and trigger all out immune response.
Defense Mechanisms: Inflammation and Infiltration of WBC's
Inflammation causes: Alveoli to fill with exudate (protein rich fluid)
Problem: Results in inefficient gas exchange
WBC's (neutrophils, macrophages, lympocytes): destroy bacteria but cause the formation of inflammatory exudate (pus)
Problem: Results in inefficient gas exchange
While recovering at home he developed pneumonia in the lower lobe of his right lung. Jimmy is at a high risk for a severe lung infection due to his weakened immune system caused by COPD.
Pneumonia Specific NIC's
1. Use a nasal cannula to deliver supplementary oxygen.
2. Use an incentive spirometer to minimize fluid buildup in lungs by opening alveoli.
3. Give warm liquids to help loosen and mobilize secretions.
4. Position client in a position that aids breathing
5. Maintain nutrition by monitoring food and fluid intake.
6. Educate patient on risk factors contributing to pneumonia. Ex: COPD, smoking.
Expected Assessment Findings
The following are findings that would indicate wound infection.
Leaking of green/yellow pus from wound
Wound that is red, warm, or increased edema
Red streaking around wound-Indication of lymph system infection.
Fever sweating and clammy skin (from pneumonia), cap refill
Peripheral Vascular
Case Study 13: Bacterial Pneumonia. (n.d.). Retrieved June 5, 2013, from http://downloads.lww.com/wolterskluwer_vitalstream_com/sample-content/9780781761451_Bruyere/samples/Bruyere_Case13_001-012_DS.pdf
Increased heart rate, tachycardia
Vital Signs
Low Blood Pressure (possible hypotension), increased respiratory rate, increased heart rate, mild to high fever (101F - 105F)
Possible sharp/ stabbing chest pain
Overall weakened muscle strength due to fatigue, possible joint pain upon range of motion exam. Gait may be impaired due to injury.
Appearance: distressed from leg pain/ pneumonia
Possible confusion, fatigued facial expression
Motor function slowed due to age, sickness
Sensory function satisfactory
Presented by:
Hayley Altshuler
Erika Bade
Julia Lange
Austin MacDonald
Jennifer Ramsey
Educational need: how, when, and why to use prescribed pneumonia treatments
Alspaugh, Lara. A Guide for Nurses: Teaching Healthcare Effectively to Patients. Health Careers Journal. Retrieved June 9th, 2013, from http://www.healthcareersjournal.com/a-guide-for-nurses-teaching-healthcare-effectively-to-patients/
Nursing Care Plan for Pneumonia with Diagnosis Interventions. (n.d.). Retrieved June 5, 2013, from http://ncpnanda.blogspot.com/2012/10/nursing-care-plan-for-pneumonia-with.html
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