This is a Unfolding Case Study Patient Details: Print Phase Info  |  Case Study History Name: James, Karen Age: 57  Years Gender: Female Karen James is a 57-year-old female who was admitted to the medical-surgical unit from her primary care physician’s office for treatment and evaluation of persistent and worsening influenza. She has a past medical history of asthma as well as depression and anxiety. You are currently working on Phase 1. You have completed Phase 0 of this scenario. Patient Details: Print Phase Info  |  Case Study History Name: James, Karen Age: 57  Years Gender: Female Phase 1, Wednesday 16:00 You have assumed care for Ms. James who is admitted to the medical-surgical unit for rehydration and management of respiratory distress. Orient yourself to the patient and health record by locating the following pieces of information within the System Assessment Report and Patient Teaching, and type your answers in a Miscellaneous Nursing Note: 1). Run a report on all the System Assessments documented for the patient in the last 24 hours. You will need to go to Patient Charting > System Assessments > Show Saved Charting. What was documented for the respiratory effort? What was auscultated in the Lower Right Posterior lobe of the lungs? What was documented related to tissue perfusion? 2). What was the last documented temperature for Karen? 3). Does Ms. James use any sensory aides? 4) What does she rate her pain? 5) What is her MORSE Fall Risk Score? Review the client's History and Physical, what indications can you see place this patient at risk for mobility issues or falls? [LEARNER ACTION: In a misc nursing note identify risks for mobility and falls. Explain her score on the MORSE scale.] When you are finished with this task, you may click Complete this Phase. Patient Information Chief Informant: Patient Chief Complaint: Shortness of breath, productive cough History of Current Problem: Patient states she has had 3-week history of influenza. Has now developed a severe cough approximately 3 days ago with shortness of breath. Unable to sleep due to cough, which often causes bronchospasms. Patient also complains of fever, fatigue, and right-sided chest pain. Seen in urgent care 3 days ago and given Z-pack. No improvement in symptoms. Allergies: None known Family History: Mother died at age of 72 with breast cancer. Father is alive at the age of 79 and has congestive heart failure. Past Medical History Previous Illnesses: Patient has asthma. Also states she gets bronchitis every 1-2 years. Contagious Diseases: None Injuries or Trauma: None Surgical History: Tonsillectomy and adenoidectomy as a child. Dietary History: Regular diet. Patient is 5'1" and 140 pounds. Has recently lost 20 pounds on Weight Watchers diet. Other: -- Social History: No smoking, no drugs. Uses alcohol in social situations. Current Medications: Tylenol 650 mg PO every 4 hours PRN pain .

1. This is a Unfolding Case Study
Patient Details:
Print Phase Info
|
Case Study History
Name:
James, Karen
Age:
57 Years
Gender:
Female
Karen James is a 57-year-old female who was admitted to the
medical-surgical unit from her primary care physician’s office
for treatment and evaluation of persistent and worsening
influenza. She has a past medical history of asthma as well as
depression and anxiety.
You are currently working on Phase 1. You have completed
Phase 0 of this scenario.
Patient Details:

2. Print Phase Info
|
Case Study History
Name:
James, Karen
Age:
57 Years
Gender:
Female
Phase
1,
Wednesday
16:00
You have assumed care for Ms. James who is admitted to the
medical-surgical unit for rehydration and management of
respiratory distress.
Orient yourself to the patient and health record by locating the
following pieces of information within the System Assessment
Report and Patient Teaching, and type your answers in a

3. Miscellaneous Nursing Note:
1). Run a report on all the System Assessments documented for
the patient in the last 24 hours. You will need to go to Patient
Charting > System Assessments > Show Saved Charting. What
was documented for the respiratory effort? What was
auscultated in the Lower Right Posterior lobe of the lungs?
What was documented related to tissue perfusion?
2). What was the last documented temperature for Karen?
3). Does Ms. James use any sensory aides?
4) What does she rate her pain?
5) What is her MORSE Fall Risk Score?
Review the client's History and Physical, what indications can
you see place this patient at risk for mobility issues or falls?
[LEARNER ACTION: In a misc nursing note identify risks for
mobility and falls. Explain her score on the MORSE scale.]
When you are finished with this task, you may click Complete

4. this Phase.
Patient Information
Chief Informant:
Patient
Chief Complaint:
Shortness of breath, productive cough
History of Current Problem:
Patient states she has had 3-week history of influenza. Has now
developed a severe cough approximately 3 days ago with
shortness of breath. Unable to sleep due to cough, which often
causes bronchospasms. Patient also complains of fever, fatigue,
and right-sided chest pain. Seen in urgent care 3 days ago and
given Z-pack. No improvement in symptoms.
Allergies:
None known
Family History:
Mother died at age of 72 with breast cancer. Father is alive at
the age of 79 and has congestive heart failure.
Past Medical History

5. Previous Illnesses:
Patient has asthma. Also states she gets bronchitis every 1-2
years.
Contagious Diseases:
None
Injuries or Trauma:
None
Surgical History:
Tonsillectomy and adenoidectomy as a child.
Dietary History:
Regular diet. Patient is 5'1" and 140 pounds. Has recently lost
20 pounds on Weight Watchers diet.
Other:
--
Social History:
No smoking, no drugs. Uses alcohol in social situations.
Current Medications:
Tylenol 650 mg PO every 4 hours PRN pain or fever
Prozac 20 mg PO every day

6. Xanax 0.25 mg PO every 8 hours PRN
Xopenex HFA 2 puffs every 6 hours PRN
Review of Systems
Integument:
Denies complaints.
HEENT:
States she had neck soreness related to influenza, with "swollen
glands."
Cardiovascular:
No complaints.
Respiratory:
Complains of shortness of breath, frequent productive cough.
States her cough often turns into bronchospasms. Uses inhaler,
peppermint tea, lozenges, and Vicks VapoRub.
Gastrointestinal:
Complains of decreased appetite.
Genitourinary:
No complaints.
Musculoskeletal:

7. Complains of generalized body aches.
Neurologic:
Alert and oriented.
Developmental:
Denies complaints.
Endocrine:
No complaints.
Genitalia:
No complaints.
Lymphatic:
No complaints.
Physical Exam
General:
57-year-old female in mild distress. Appears weak.
Vital Signs:
Temp: 103.2 F, Pulse: 114, Resp: 28, Blood pressure: 154/78 in
office this morning

8. Integument:
Skin clear of rash.
HEENT:
Pupils equal and reactive. Nasal congestion. Neck supple.
Cardiovascular:
S1, S2, no murmur.
Respiratory:
Lungs clear with crepitation in right base.
Gastrointestinal:
Abdomen soft, active bowel sounds.
Genitourinary:
--
Musculoskeletal:
Moves all extremities well.
Neurologic:
Alert and oriented.
Developmental:
--

9. Endocrine:
--
Genitalia:
Not assessed. Seen by gynecologist recently. Negative pap
smear and negative mammogram.
Lymphatic:
No lymph node swelling at this time.
Impressions:
Pneumonia
Plan:
The patient is admitted for IV antibiotics and close observation
of respiratory status. Patient will need influenza and pneumonia
vaccines.
Provider Signature:
Michael Foster, MD
Day:
Wednesday
Time:
12:45
Chief Complaint:

10. The patient is a 57-year-old female admitted today for chief
complaint of shortness of breath.
Patient's labs were completed in the primary care provider's
office prior to admission and results include the following:
WBC: 20.2 x 109/L
RBC: 4.51 RBC x 106/ul
Hemoglobin: 14.0 g/dL
Hematocrit: 40.2%
Sodium: 139 mEq/L
Potassium: 4.2 mEq/L
Chloride: 105 mEq/L
CO2: 26 mEq/L
Glucose: 91 mg/dL
BUN: 17 mg/dL
Creatinine: 0.5 mg/dL
She is also febrile at 102.7.
Nursing will initiate IV antibiotics.
Showing 1 to 1 of 1 entries

11. FirstPrevious1NextLast
Chart Time
Temp
Resp
Pulse
BP
Sat%
Notes
Entry By
Wed 12:45
102.7

12. 22
112
142/77
98
C Diaz, RN
Select Chart Type:
Temperature Respiration Pulse Blood Pressure Oxygen
Saturation
Select and drag to zoom in on a date range
102.7F/39.3C
Patient Card

13. Order Day/Time
Description
Category
Last Performed
Discontinue
Wed | 13:00
Admit to medical-surgical
Alerts
--
Wed | 13:00
Start and maintain IV line

14. IV
--
Wed | 13:00
Pulse oximetry every 4 hour(s)
Respiratory
--
Wed | 13:00
Vital signs every 4 hours
Vital Signs
--

15. Wed | 13:00
Up as tolerated
Activity/Mobility
--
Wed | 14:00
Diagnosis-Respiratory distress syndrome-ADDED-Disease
Process
Patient Teaching
--
Wed | 13:00

16. Regular/General Diet
Diet
--
Showing 1 to 7 of 7 entries
FirstPrevious1NextLast
PRN
Drug Name
Order Start
Order Stop
Dose
Route
Frequency

17. Dosage Time
Action
Acetaminophen Tablet - (Tylenol, Genapap)
Wed 13:00
Tue 23:59
650 mg
Oral
Every 6 Hours PRN
- -
Levalbuterol Nebulizer

18. Solution
- (Xopenex Nebulizer