Video Case Study - Pneumonia

Nurse Jodie works on a Medical-Surgical unit and is caring for Ann, a 44-year-old female with a history of smoking who was recently admitted for community-acquired pneumonia. After settling Ann in her room, Nurse Jodie goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Ann's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Jodie recognizes important cues including Ann's vital signs, which are temperature 101.5 F or 38.6 C, heart rate 101 beats per minute, respirations 28 breaths per minute and regular, blood pressure 90/60 mmHg, and oxygen saturation 85 percent on room air. Upon auscultation, Nurse Jodie notes course crackles and slight wheezing. Nurse Jodie also observes that Ann can't speak in full sentences without becoming short of breath.

Next, Nurse Jodie analyzes these cues. Nurse Jodie reviews the electronic health record, or EHR, and notes Ann's WBC count is elevated at 12,500 per mm3. Nurse Jodie knows that an infection is likely causing fluid to fill up Ann's alveoli which is interfering with gas exchange; and that inflammation is causing her airways to narrow. Nurse Jodie recognizes that Ann needs effective respiratory management.

Nurse Jodie chooses a priority hypothesis of ineffective gas exchange.

Then, Nurse Jodie generates solutions to address Ann's infection. She establishes the expected outcome that after intervening, Ann will maintain an oxygenation saturation above 92 percent during the shift.

Nurse Jodie then takes action to implement these solutions.

Nurse Jodie: I'm going to give you some oxygen to help you breathe a little easier. This plastic tubing will go around your ears and the prongs will go into your nose. It's important that you breathe in through your nose so the oxygen will go into your lungs.

Ann: Okay, I hope it helps.

Nurse Jodie: Your health care provider also ordered an antibiotic called ciprofloxacin, some fluids to go through your IV, and these acetaminophen tablets to help with your fever.

Ann: Okay.

Nurse Jodie administers the fluids, acetaminophen, and antibiotic according to the principles of safe medication administration. Then she assists Ann to a position of comfort and ensures her antibiotic is infusing properly. Nurse Jodie dims the lights and gives Ann the call bell before she leaves the room.

Three hours later, Nurse Jodie enters Ann's room to evaluate the outcomes of her actions. She takes Ann's vital signs which are temperature 99.1 F, or 37.3 C, heart rate 84 beats per minute, respirations 21 breaths per minute and regular, blood pressure 112/68 mmHg, and her oxygen saturation is 94 percent on 2 liters of oxygen per nasal cannula. Ann is also now able to speak in full sentences.

Nurse Jodie: How are you feeling, Ann?

Ann: A little bit better.

Nurse Jodie: That's great! I also wanted to ask you about a pneumonia vaccination. Have you ever received one?

Ann: No, my doctor offered it to me when I got my flu shot, but I didn't want it.

Nurse Jodie: Well, we can give it to you while you're here, after you're feeling better. It'll help prevent you from getting pneumonia again in the future.

Ann: Okay, thanks.

Alright, as a quick recap... Nurse Jodie recognized and analyzed cues related to Ann's community-acquired pneumonia and prioritized hypotheses and generated solutions to address this problem. Nurse Jodie then implemented pharmacologic measures to address Ann's infection, and evaluated her outcomes, comparing them to the expected outcomes. Since Ann's oxygen saturation goal was achieved, Nurse Jodie determined that the plan of care was successful.