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Stenberg College NURS 201-3 Weekly Case Study and Care Plan
Clinical group Members: Andrea Geib, Lorna Muenz, Kristina Day, Sasha Yunick, Jill
Shaw, & Michelle Couper
Date: June 2th -8th 2014
Case Study Critical thinking questions
NURSING MANAGEMENT: Lower Respiratory Problems
Aspiration Pneumonia
Client Profile
Sam, a 27-year-old man, was admitted to the hospital because of an uncontrollable fever.
He was transferred from a long-term care facility. He has a history of a gunshot wound to
his left chest. Following a cardiac arrest after the accident, he developed hypoxic
encephalopathy. He has a tracheostomy and gastrostomy tube. He has a history of
methicillin-resistant Staphylococcus aureus (MRSA) in his sputum.
Subjective Data
·Family says that they visit him regularly and are very devoted to him.
Objective Data
Physical Examination
·Thin, cachectic man in moderate respiratory distress
·Unresponsive to voice, touch, or painful stimuli
·Vital signs: temperature 40°C (104°F), heart rate 120, respiratory rate 30, O2 saturation
90%
·Chest auscultation revealed crackles and scattered wheezes in the left upper lobe
Diagnostic Studies
·Serum albumin 28 g/L (2.8 g/dL)
·White blood cell (WBC) count 18 × 109/L (18,000/μL)
·Sputum specimen: thick, green-coloured, foul smelling; cultures pending
·Arterial blood gases: pH 7.29, PaO2 80 mm Hg, PaCO2 40 mm Hg, bicarbonate 16
mEq/L
·Stool culture positive for Clostridium difficile
·Chest x-ray: infiltrate in left upper lobe; no pleural effusions noted
Critical Thinking Questions
1.What types of infectious disease precautions should be taken related to Sam’s
hospitalization?
Sam’s stool culture tested positive for Clostridium difficile and his sputum tests are still
pending but since he has had a history of methicillin-resistant Staphylococcus aureus
(MRSA) and his sputum was observed to be thick, green, and foul smelling, there is
strong indication that an infection exists and he could test positive for MRSA. Two levels
of infectious disease precautions should be taken due to his positive test for C Diff and
suspected MRSA infection (Kwong & Springer, 2014). These two levels of precaution
include standard precautions and transmission based precautions (Kwong & Springer,
2014). The standard precautions system applies to blood, all body fluids, non-intact skin,
and mucous membranes (Kwong & Springer, 2014, p. 321). Transmission based
precautions are designed for patients suspected of or known to be infected with highly
transmissible pathogens in which additional precautions need to be implemented to
interrupt transmission (Kwong & Springer, 2014). Three types of transmission based
precautions include airborne, droplet and contact (Kwong & Springer, 2014, p. 321). In
Sam’s case standard precautions would apply as well as contact (transmission based)
precautions as MRSA and C Diff can be transmitted through direct contact with infected
individual or environmental surfaces (Kwong & Springer, 2014). These precautions
would include hand hygiene, gloves, mask, eye protection, face shield, gown, linen, and
patient transport (pp. 320-321).
Hand Hygiene procedure: wash hands using either soap or alcohol-based hand rubs.
This should be done before initial contact with patient or his environment, before aseptic
procedures, after body fluid exposure risk, and after contact with patient or environment
(Kwong & Springer, 2014, p. 320).
Gloves: wear nonsterile gloves when touching blood, body fluid, secretions, excretions,
and contaminated items. Remove promptly after use. In Sam’s case contact precautions
would be implemented as well which would include wear gloves when entering the rom
and whenever providing direct care or having hand contact with contaminated surfaces
(Kwong & Springer, 2014, p. 320).
Mask, Eye Protection, Face Shield: wear to protect mucous membranes when
administering direct care and more specifically in situations when dealing with blood,
body fluids, secretions and excretions. Wear within 1 m of coughing patient.
Gown: since Sam has diarrhea it is especially important to wear gown especially if
substantial contact is required. Remove and discard properly immediately after use
(Kwong & Springer, 2014, p. 320).
Linen: handle, transport, and process used linen in a manner that prevents sin exposure
and contamination (Kwong & Springer, 2014, p. 320).
Patient Transport: limit movement of patient unless absolutely essential; if transport is
necessary minimize contamination of environmental surfaces or environment (Kwong &
Springer, 2014, p. 320).
In addition to the above precautions, best practice guidelines suggest that individuals
infected with C Diff should be isolated and have a private room and bathroom and
signage indicating the precautions that should be used (p. 1165).
Kwong, J. & Springer, L. (2014). Medical Surgery Nursing in Canada. Toronto, ON:
Elsevier Mosby
 2/2
2. What clinical manifestations of aspiration pneumonia did Sam exhibit? Explain
their pathophysiological bases.
Signs and symptoms of aspiration pneumonia that Sam exhibits is a fever, respiratory
distress, crackles and wheezes in left upper lobe, increased heart rate, and O2 saturation
of 90%. All elevated vital signs are due to the underlying infection while the low o2 sat
and crackles and wheezes are due to the aspirated materials in his lungs. Crackles sounds
in the chest, can either be fine or coarse sounding. If the crackle sounds are fine, this
indicates fast equalization of gas pressure when the alveoli are distorted, or the terminal
bronchioles open up abruptly. If the crackles are coarse, this is caused by mucosa
blocking the airway intermittently; resulting in air not being able to pass through, or the
bronchial wall is unstable. The aspirated material that entered Sam’s lung is the reason
for Sam developing this type of pneumonia; also with Sam not responding to voice, touch
or painful stimuli, this suggests that he may be unconscious. With Sam potentially being
unconscious, his cough and gag reflexes are depressed, and the chances of him aspirating
are even higher. White blood cell count is high (18, 000/uL) showing signs of infection
because normal white blood cell count is approximately 3,500-10,500/uL. With Sam
having such high white blood cell count, his body is working very hard to fight off the
infection by itself.  2/2
Crimlisk, J. & Bolan, C. (2010). Nursing Management: Lower respiratory problems. In
Lewis, S., Heitkemper, M., Dirksen, S. R., O' Brien, P. G., Barry, M., Goldsworthy, S., &
Goodridge, D. (Eds.), Medical-surgical nursing in Canada (2nd ed.) (pp. 626-669).
Toronto, ON: Mosby Elsevier.
3. What antibiotic medication is likely to be prescribed?
The patient has MRSA which means standard antibiotics will not work in treating his
pneumonia. The most recommended medication that would be prescribed for him is
Vancomycin (Table 17-6 pg 318).
According to WebMD Vancomycin,  an antibiotic is prescribed for treating serious
bacterial infections by stopping the bacterial growth. It is most commonly given
intravenously however when used to treat C-Diff it is taken orally where it remains in the
intestines to stop bacteria growth and is not absorbed into the rest of the body. 1/1
The above patient would be prescribed oral to treat his C-Diff and IV to treat his
pneumonia.
WebMD. (n.d.) Drugs & medications – vancomycin. WebMD. Retrieved from:
http://www.webmd.com/drugs/drug-939-Vancomycin+IV.aspx?drugid=939
4. What is his oxygenation status and metabolic state?
4. What is his oxygenation status and metabolic state?
His O2 saturation is 90% while arterial blood gasses show: pH 7.29, paO2 80 mmHg,
PaCO2 40 mm Hg, and a Bicarbonate 16 mEq/L. The blood gas readings show the
patient is at risk for metabolic acidosis. This means that in order for his body to
compensate, his CO2 levels increases to compensate and thus his breathing increases, and
is not getting enough O2, thus giving him a deficit in bicarbonate (16mEq/L). The fact
that his “Chest auscultation revealed crackles and scattered wheezes in the left upper
lobe” and is in “moderate respiratory distress” explains that he is having trouble
breathing, thus heart rate is up and is having problems with O2, he will need O2 therapy
to get his breathing and heart rate back to normal and less distressed. This is called
hypoxia.
1/1
Malone, M. (2014) Nursing Management: Lower Respiratory Problems. In M. Barry, S.
Goldsworthy & D. Goodridge (Ed.) Medical-Surgical Nursing in Canada: Assessment
and management of clinical problems (3rd Canadian ed.) (pp. 658-708) Toronto, ON:
Elsevier Canada.
5. What other clinical issues need to be addressed in his plan of care?
Looking at the predisposing factors for pneumonia, Sam has a few, the first one identified
is his altered state of consciousness, the next factor would be bed rest and prolonged
immobility, as well as intestinal and gastric feedings and lastly tracheal intubation
(Malone, 2014, Table 30-1, p. 660). Other clinical issues would be in connection to these
factors. Because of his clinical situation, he is at risk for aspiration because of his
neurological status.
This patient has a complex care plan to deal with, because he is in a compromised
position, with being in a coma, it is the nurse’s responsibility to follow all precautions for
the care of Sam. Starting with universal precautions for MRSA, they would include hand
hygiene; gloves, mask, eye shield; gown and linen care (Malone, 2014,) as well as
documenting on the patients chart so the healthcare team is well informed. Utilizing a cart
outside the patient’s room and having all the supplies needed on hand will help to remind
the team of the patients needs.
Therapeutic positioning for a patient with pneumonia, would generally be with the
patient’s head slightly elevated and positioned on his side with the good lung down, for
the lung “to achieve maximum lung expansion” Malone, 2014, p.666). Although with the
tracheostomy and the feeing tube the patient would be monitored easier on his back.
Turning of this patient would need to be addressed every two hours ”to facilitate adequate
lung expansion and to discourage pooling of secretions” (Malone, 2014,).
Aseptic technique for the care of his tracheostomy and gastric tubes is very important to
reduce the chance of hospital-associated infection, hand hygiene and sterile suctioning
techniques are important for reduction of these infections. “Respiratory devices can
harbor microorganisms and have been associated outbreaks of pneumonia”(Malone,
2014, p.666).
The treatment of clostridium difficile also know as C. difficile is for the most part
prevention of the spread of the disease. C. diff is caused in “patients who are taking
certain antibiotics in high doses over a prolonged period of time”( phac.gc.ca, 2014). The
bacteria causes abdominal cramping and watery diarrhea. Transmission of this disease is
through people not washing their hands after contact with feces. “People can get infected
if they touch surfaces contaminated with feces, and then touch their mouth” (phac.gc.ca,
2014). In mild cases treatment is not always needed, in severe cases medication and
surgery could be warranted (phac.gc.ca, 2014). For Sam medication and universal
precautions for the transmission of the bacteria would be the best treatment.
1.25/2 Nursing measures should be directed toward prevention of aspiration. He is
malnourished as evidenced by hypoalbuminemia and cachectic condition, and the reasons
for this need to be investigated.
phac.gc.ca (2014)Fact Sheet - Clostridium difficile (C. difficile) Public Health Agency of
Canada. Retrieved from http://www.phac-aspc.gc.ca/id-mi/cdiff-eng.php
Malone, M. (2014) Nursing Management: Lower Respiratory Problems. In M. Barry, S.
Goldsworthy & D. Goodridge (Ed.) Medical-Surgical Nursing in Canada: Assessment
and management of clinical problems (3rd Canadian ed.) (pp. 658-708) Toronto, ON:
Elsevier Canada.
6.What family interventions would you initiate?
We would discuss with the family how Sam’s previous and present diagnosis’s when all
combined are having very negative effects on his health. Explaining to the family about
what pneumonia is, how it is affecting Sam, and how it is usually treated would be
important. We would also have to explain to the family that because of Sam’s MRSA,
unfortunately antibiotics will not be effective in treating his pneumonia. At this time it
would be important to speak to the family about a DNR and the patient’s quality of life,
especially with his current status. Discussing comfort measures and palliative care
options, as well as looking at family support systems and recommending grief
counselling is also crucial. We would provide the family with as many resources possible
regarding Sam’s health issues, and also any supportive resources. 1/1
7. Based on the assessment data presented, write one or more appropriate nursing
diagnoses. Are there any collaborative problems? 0.5/1
Nursing Focus of Care / Nursing Diagnosis
Collaborative problems
Domain 11: Safety/Protection
Infection, respiratory distress, prolonged bed rest,
increased secretions and impaired swallowing due to
tracheostomy.

Risk for Aspiration

Domain 11: Safety/Protection
Risk for Contamination

Domain 9: Coping/Stress tolerance
Compromised family coping

Patient is positive for MRSA and C-Diff isolation
precautions must be taken to prevent the spread of
diseases to nurse or other patients; aseptic technique,
gloves, gown, mask, eyewear, hand washing, isolation
room, linens and equipment sterilization. 
Family at risk for denial, fear, grieving, depression,
helplessness, and guilt.

5/5
Malone, M. (2014) Nursing Management: Lower Respiratory Problems. In M. Barry, S.
Goldsworthy & D. Goodridge (Ed.) Medical-Surgical Nursing in Canada: Assessment
and management of clinical problems (3rd Canadian ed.) (pp. 658-708) Toronto, ON:
Elsevier Canada.
Stenberg College RDPN Program
Nursing Care Plan
Nursing
Diagnosis
Desired
Outcomes
Interventions (I)Independent
(C) - Collaborative
Rationale & APA
Reference
Evaluation of
Interventions
NDX: (Problem)
Goal
(Reversal of
Problem)
N1-(I) (C)
R1-Single most
important thing you can
do to prevent an
infection
E1-Ensure hand
sanitizer or access to
soap and running water
are available outside
patient’s room and
nurses are aware of
isolation precautions.
Risk for
Contamination
R/T:
(etiology/factor):
MRSA
Treat and
protect against
spread of
infectious
disease
Hand hygiene
(author, Pg. 319)
Author Pg. 319
Nursing
Diagnosis
Desired
Outcomes
Interventions (I)Independent
(C) - Collaborative
Rationale & APA
Reference
Evaluation of
Interventions
C-Difficile
Patient in
coma
N2-(I) (C)
R2-Non-sterile gloves
should be used when
touching bodily fluids
and changed frequently
in between tasks.
E2-Ensure clean
gloves are available,
accessible and fully
stocked in different
sizes.
Author, Pg. 320
Pg. 320
R3-Protect against
splashes or spray from
bodily fluids
E3-Nurse must wear
these within 1 meter of
coughing patient
Pg. 320
Pg. 320
R4-Protect skin and
prevent clothing soil
during patient care. 
E4-Assessment of
specific risk
determines the type of
gown to be worn. eg,
fluid resistant.
AEB: (s/sx;
defining
characteristics)
1. sputum text
positive for
MRSA
2. Stool positive
for C-Difficile
*If ‘risk for’
would exhibit:
Gloves
Nurse will
(list
measurable
outcomes;
reverse signs
and
symptoms)
1. use of
proper
isolation
measures
2. prevent the
spread of
contaminable
diseases to
staff, patients
and public
N3-(I) (C)
Mask, eye protection
and face shield
N4-(I) (C)
Gown
Pg. 320
Pg. 322
N5- (I) (C)
3. proper
documentation Linen
Evaluation of
Outcomes
(address each
outcome)
1. contain and
prevents the
spread of
infectious
contaminants.
2. use of
isolation and
protective
measures with
all people
accessing the
patient
3.Make sure
R5- prevents skin and
mucous membrane
exposure.
Pg. 321
R5- make sure pts
room has accessible
laundry bins, and
supplies readily
available
Pg. 321
N6- (I) (C)
R6- limit movement
and transport to prevent
spread of disease.
E6- transport for
essential services and
place mask on pt.
Pg. 321
Pg. 321
N7- (I) (C)
R7-
E7-
Treatment of C-Diff
with
?
?
Limit Patient Transport
Nursing
Diagnosis
Desired
Outcomes
Interventions (I)Independent
(C) - Collaborative
Rationale & APA
Reference
Evaluation of
Interventions
chart is
labelled and
isolation
precautions
are posted on
pts room
Evaluation of
Goal:
Goal met – if
all isolation
precautions
and protection
measures are
taken and
followed by
staff and
visitors.
(If goal not
met, describe
outcomes not
met)
Continuation
of plan:
(circle one)
Continue
plan of care
until patient
discharged.
All of your interventions should be under one umbrella of isolation precautions. There are
some important measures that you missed in your care plan to deal with infection – ie
medications, blood work, mobilization –even if it is in bed and chest physiotherapy.
These are all important aspects of monitoring the body to treat and prevent infection.
2.5/5
Kwong, J. & Springer, L. (2014) Infection and Human Immunodeficiency Virus
infection. In M. Barry, S. Goldsworthy & D. Goodridge (Ed.) Medical-Surgical Nursing
in Canada: Assessment and management of clinical problems (3rd Canadian ed.) (pp.
314-343) Toronto, ON: Elsevier Canada.
16.25/20
Some work needs to be done on your care plan. See my comments. Your critical
thinking questions were very well done. Don’t forget about the collaborative nursing
diagnoses – these can just be listed.