Problem
Cindy is a 24-year-old female who was admitted to your medical unit two days ago with a diagnosis of right middle lobe pneumonia. She has been complaining of chest pain and shortness of breath for the past 24 hours, with no relief from acetaminophen or ibuprofen administration.
According to her chart, Cindy has been living at a women's shelter in the downtown area for the last 3 weeks due to experiencing escalating violence while working as a sex-trade worker. She has a history of smoking cigarettes, marijuana and crystal meth. She doesn't have a family physician or nurse practitioner.
You have been assigned to look after Cindy. After receiving report you enter Cindy's room and note the following:
Cindy is sitting at the side of her bed in a tripod position. She is pale, tremulous and speaking in 3-4 word sentences. Cindy is complaining of 8/10 chest pain to her right anterior and lateral chest wall, and states the pain increases in intensity when she moves or takes a deep breath.
Vital Signs: Temp 39.8C, HR 128, RR 28, BP 92/54, O2Sats 86%RA.
GCS 15/15, pupils equal and reactive at 4mm bilaterally, strong hand grasps and leg movement bilaterally with tremors noted to both hands.
Respiratory effort includes intercostal muscle use to entire chest wall, with some sub-costal effort. No complaints of pain to palpation over entire thoracic cavity. Lung sounds auscultated and diminished air entry and crackles noted to RML with faint crackles heard to RUL and RLL. Clear air entry present to left lung field. Percussion reveals resonance to left lung fields and dullness heard to right mid thorax. Increased tactile fremitus to right side. Cindy complains of increased pain while chest auscultated.
Skin pale and hot to touch. Bounding radial pulse palpable X 2, peripheral pulses are strong X 6. Heart sounds auscultated, S1 and S2 present. No murmurs or extra heart sounds present.
Abdomen soft, no distension noted, bowel sounds hypoactive to four quadrants, no pain on palpation X 4 quadrants.
Genitourinary system unremarkable.
• What are the key components in Cindy's history and assessment that you are concerned with? Provide rationale.
• What other information would you like to elicit from this patient or available family members/ friends? Provide rationale.
• What vital signs or assessment findings are a priority and will require action? Provide rationale.
• What immediate clinical interventions (nursing and medical) will you perform and anticipate performing for this patient?
Provide rationale.
The resident comes and assesses this patient and gives the following orders:
Bedrest with bathroom privileges
O2 to keep sats above 92%
VS q4hr call if HR >125 or BP<100 systolic
IV access and NS at 125mL/hr
0.9% NS 500mL IV bolus now
Tylenol 325 - 650mg po prn q4-6 hrs
Sputum sample for C & S
Chest x-ray
CBC and differential
Blood gas
Blood cultures
• What will you do first and why? List the first three orders you would complete. Prioritize and provide rationale for your decisions.
After completing all the orders, you analyze the arterial blood gas results recently drawn from Cindy.
pH 7.33
PaC02 52mmHg
Pa02 77mmHg
HCO3- 26 meq/L
SaO2 86% (RA)
Cindy's symptoms and fever continue to worsen despite administration of IV antibiotics.
• What are the possible reasons for this? What actions might you take?
The nurse practitioner orders the following: Vancomycin 500 mg IV q12h. The drug is supplied in a 500 mg vial. Reconstitute 500 mg vials with 10 ml NS or sterile water for injection.
• What is the final concentration of Vancomycin once the medication is reconstituted?
• How much Vancomycin should you draw up from the vial to administer the ordered dose?