Appendices: Case study for Pneumonia

Day 3: Medical unit

Annabelle Liao

Day 3

Time: 07h00

Place: Medical Unit

Tracie walks slowly up the walkway behind a patient in a walker entering the hospital. She remarks to herself, “Wow. My third dayshift. I didn’t think I would miss the changeover time to nights.”


“Here, let me get the door for you,” Tracie says as she opens the door for an elderly patient who then asks directions to the Ultrasound Department. Tracie points him in the direction of the Diagnostics Department and explains that he can follow the blue line right to the check-in desk.


Tracie turns in the opposite direction and enters the elevator that takes her to the seventh floor. The doors open, and she is greeted with the familiar disinfectant smells. Walking quickly to the staff room, she shrugs out of her coat and puts on her duty clogs. Looking in the mirror, she moves errant strands of hair behind her ears and runs her hands over her uniform. “I guess I’m ready. Let’s go see if anything has changed overnight.”


Walking out of the staff room to the main nursing station, Tracie finds Jim finishing off his night’s charting.


Jim looks up. “Wow, I am glad to see you.”


“Okay, that answers my first question. I have the same assignment as yesterday?”


Jim smiles. “Yes, you do. I asked specifically to keep you with the same group of patients as you know then and it will provide some consistency.”


“Are you ready to hand over to me?”


“Just give me a minute to finish this last note and chart my meds that I just gave to Room 5. It has been very busy, and I have not really had a chance to sit down all night.”


“Ok, I am going to grab a glass of water. I’ll be right back.”


A few minutes later, Tracie sits down beside an obviously exhausted Jim to get the handover report.


“Where to start? Let’s start with Ms. Miki Huang if that is okay?”


“Sure. I am hoping she had a quiet night.”


“Yes, she had a better night than her roommate and some of the other patients on the floor. Last night we needed to adjust her oxygen up as her sats went to 90% and even dropped further with movement. The RTs saw her a number of times but elected not to do an ABG at this time.” Jim points at the vital signs flow sheet. “Her heart rate, temp, and BP are up slightly from what you recorded yesterday. Ins and outs are even balance. She is due for lab work this morning, a CXR and potentially an ABG, especially if you can’t decrease her oxygen.”


“If I remember correctly, the Physio will also assess her. Is she still on IV antibiotics?”


“Yes, it’s only day two and we have no results from the sputum sample in the system. We could be changing them tomorrow if we get the culture/sensitivities then. Her next antibiotic is due at 10h00 and she has some other meds at 08h00.”


“Great, who is next?”


Jim then goes through the rest of the patient assignment.


Leaning back in his chair, Jim rubs his hair through his closely cropped hair. “That’s it for me. I’m going to change into my gear and cycle home in time to take the kids to school. Any questions?”


“Nope. Have a good sleep.”


“See you tonight. I’m scheduled to come in.”




Jim walks quickly to the staff room and then disappears through the door. Meanwhile, Tracie takes a quick look through her patient chart to plan her priorities for the day.


“Bed 5 is ready for discharge, so should be okay for the next little bit. Beds 6 and 7 had a rough night. I will see them and then be off to check on Ms. Huang.”


Sighing a little as she stands, Tracie heads off to Bed 6.

Time: 08h15

“Good morning Ms. Huang, how are you doing? Good to see you too, Linda.”


Tracie looks towards Miki and sees a very sleepy elderly woman. “Wow, she looks like she has aged even more since yesterday,” she thinks to herself.


Miki looks up and attempts to say something, but it comes out as “Argg argg.” Her voice is muffled by the mask and the sound of the bubbling from the humidifier.


Linda frowns, “What’s that, Mom?”


Tracie also furrows her brow. “Hmm, that doesn’t sound right,” she mutters to herself.


She pulls the vital sign machine up to the bedside and hooks Miki up. Immediately, she notes that Miki’s oxygen saturation is down again to 90%, then thinks to herself, “Okay, I am going to have to call the RT. May need to adjust her FiO2.” About a minute later, the machine beeps and the vitals are displayed on the small screen. Tracie records them on the vital sign flow sheet.


Day: 3 Pulse Rate Blood Pressure Respiratory Rate Temperature O2 Saturation
Time: 08h00 96 170/90 22 36.5°C 90% on FM


“Ms. Huang, I am going to listen to your lungs and heart.”


“Mom, she’s just going to check your lungs and heart, okay?” Linda translates.


Miki nods her head, “I do feel really tired though.”


Tracie places the stethoscope in her ears and bell against Miki’s chest. She quickly moves the bell around her chest in a systematic manner. Standing up straight and stretching her arms out after leaning over the bed, she thinks, “There seems to be slightly coarser sounds mid to lower field bilaterally. A few wheezes on expiration. Heart sounds are normal.”


“Ms. Huang, I am going to give you some Ventolin and ask the RT to come and see you to make sure you are on the right oxygen setting.”


Miki doesn’t react to this, but Linda nods worriedly and tells Tracie that her mother is very tired.


Tracie heads over to the nursing station and asks the unit coordinator to page the RT for her.


A few minutes later, the RT, Herman, calls back.


“Hey, this is Herman; I am the RT covering the floors today.”


“Thank you for calling back so quickly. Did you get the report on Ms. Miki Huang?”


“She’s the lady on the seventh floor with pneumonia and COPD, and on high flow face mask?”


“Yes, that is Ms. Huang. This morning when I assessed her, she mentioned being pretty tired. Sats are around 90%, RR is up slightly along with HR and blood pressure (BP). Breath sounds are a bit coarser in the lower fields with wheezes on expiration in the upper. I have just started her on some Ventolin. I am not sure about adjusting her FiO2 further or whether her COPD is getting worse which is causing her to feel tired. There is an order for an ABG if there is a change in patient’s condition. I would like you to come and see her.”


“Sounds like I should pop up there. I am seeing a patient on the fourth floor right now and titrating his oxygen. Can you wait about 10 minutes?”


“I can. I am pretty sure Ms. Huang will be okay as well. I will recheck her saturations after the Ventolin treatment.”


“That’s an excellent idea, I will be up as soon as I can.”


“Thanks.” Tracie hangs up the phone. Pushing back the loose strands of hair behind her ears, she stands up and heads down the hallway again to Ms. Huang’s room. Entering the room, she finds a very tall, fit, woman leaning over the bedside of Ms. Huang.


“Can I help you?” Tracie asks.


“Hi, my name is Gladys. I am a Physio student doing a preceptorship, and Ms. Huang’s name is on our list of patients to see today. I thought I would come by and see Ms. Huang to see what physio she needs and then plan a time to come back to do physio with her.”


“Oh, okay. Sorry, I didn’t see your name tag. My name is Tracie, and I am the nurse caring for her. I don’t think this morning is a good time. Ms. Huang’s oxygen saturations are down a bit and her breath sounds are a bit coarser than yesterday. Last night she required an increase in her FiO2.  She has been complaining of feeling tired and seems a bit sleepier than usual.”


Gladys looks down at Miki, who is propped up with a few pillows at 45 degrees.


“Tracie, would you have a few minutes to help me reposition Ms. Huang? I think I can help improve her saturations with better position for expansion and maybe lead her to do some deep breathing exercises and coughing exercises to help move her secretions out.”


“I can help.”


“Okay, I am just going to get a bolster. Can you find a couple more pillows for me?”


“Yes, I think so. There is always a shortage of pillows. Most are like placemats, and patients are always hoarding them as one is never fluffy enough.”


Gladys smiles and moves out the door to the storeroom to find a bolster.


A few minutes later, both Gladys and Tracie are standing together at the end of the bed looking at Miki, who stares back cautious.


“Okay Gladys, what are we going to do?”


“I would like to position Ms. Huang more upright in bed with her arms resting on pillows on the overbed table. I am not familiar with these beds, but I believe we can move the foot of the bed, so Ms. Huang is in more of a sitting position?”


“Sounds good; let’s get started.”


Throughout this exchange, Linda is not present, and Miki is growing increasingly anxious. As much as she hates admitting it, she is reliant on her daughter now more than ever. Sure, at home Linda took care of Miki’s physical needs, but ever since they got to the hospital, Linda also took over anything related to communication. “If only I had tried harder to learn English in the past,” Miki thinks to herself wistfully, and not for the first time since she arrived either.


Now, in bed, she feels completely in the dark about what the doctors want to do with her. What if it hurt? What if something went wrong? Where was Linda when she needed her most? Miki notices Gladys gesturing towards her, seemingly trying to demonstrate what they wanted to do. Miki only grips the bed railing tighter.


Both Gladys and Tracie work together to move Miki into a chair-like position while in bed. They place the bolster at Miki’s back to ensure correct body alignment. After positioning Miki, both step back to admire their work, but Miki’s heart is pounding rapidly. Was that it? Did they only need to adjust her position?

Miki is sitting up, leaning forward onto the bed tray propped up by pillows. She is aided by nurse Tracie and physio student Gladys
Day 3 – While wearing a breathing mask, Miki is placed in a position by the respiratory therapist and nurse. Image created by Sarah Pinault under a CC-BY-NC license

Just then, Linda returns from the bathroom. “Oh, hi there. What’s happening?”


“I’m going to check Ms. Huang’s vitals again to see if this movement helped. I’ll go get the machine to do that.”


“I am going to see if I can get her to deep-breathe and cough. Maybe moving or clearing those secretions will help.”


Gladys moves closer to Miki. “Okay, Ms. Huang, I want you to take a deep breath.”


“Take a deep breath, Mom,” Linda instructed.


Miki takes a week breath in through her mouth. “That’s great. And now breathe out.” Miki coughs weakly.


“That is very good Ms. Huang. I want you to take a slow deep breath to the count of three, then breathe out to the count of three.” Gladys demonstrates what she is asking.


Miki understands that she’s imitating what she wants and nods her head. “Okay, breathe in, 1, 2, 3. Hold. Breathe out 1, 2, 3. Very good.” Miki begins coughing and makes frantic motions with her hands to remove the O2 mask. Gladys removes the mask and hands a tissue to Miki. Miki coughs a moderate amount of green sputum into the tissue.


Behind them, Linda winces, but Gladys is happy. “This is exactly what we want to see! Let’s do the breathing and coughing exercises some more and see if we can clear your lungs a bit.” Gladys then leads Miki through five more deep breathing and coughing exercises with Linda’s assistance. At the end of each deep breath, Miki coughs out more greenish/yellow sputum.


At the end of the fifth attempt, Tracie walks into the room with the vital sign machine. “Sorry, I had to answer Bed 6’s call bell. Did I miss anything?” Tracie walks to Miki and attaches the machine to her arm and finger.


Gladys smiles, “Do we need a sputum sample? Ms. Huang has coughed out quite a bit of stuff.”


“No, I don’t think so. One was sent from Emergency that we are still waiting on. If she is coughing now, we can always have you come back and assist us to get another specimen.”


The vital sign machine beeps and displays the vital signs on the screen. Saturations are up quite a bit and HR and BP are back to normal for Miki. Temperature is still low-grade fever. Tracie records the vital signs.


Day: 3 Pulse Rate Blood Pressure Respiratory Rate Temperature O2 Saturation
Time: 09h00 86 150/85 18 36.5°C 95% on FM


“Wow, great improvement Ms. Huang. Getting you up in bed and breathing better has certainly helped.” Miki smiles weakly at the encouraging tones.


Tracie stares at Miki for a moment longer and thinks, “She looks more alert, eyes are open, better eye contact…overall she looks much better than when I first came on shift.”


The RT, Herman, arrives in the room and looks at Ms. Huang, Linda, Gladys, and Tracie. “Hi, I’m Herman. You paged me earlier to come and see Ms. Huang.”


“Hi Herman. I’m Tracie and this is Gladys, a physiotherapist. And this here is Linda, Ms. Huang’s daughter. Since Ms. Huang cannot speak English, she’s helping out as a translator.”


“Happy to meet you all. So, what can I do to help Ms. Huang here?” Herman moves closer to Miki, checks her mask, and then works his way back to the humidifier and checks the flow meter on the wall. He nods his head, thinking, “Exactly like I was told. No real changes in therapy.”


Tracie then gives a quick report including changes overnight and what happened thus far this morning.


Herman rubs his chin. “Okay, she has improved with physio but is still on high flow. We know she is a CO2 retainer which may explain her being sleepy this morning, and she has not had an ABG since being in Emergency. Doctor orders give me some leeway on taking an ABG. I would like to do an ABG and see where we are and if there are really any changes since Emergency. From her saturations here it looks like we could drop her FiO2 a bit. So, let’s do this: I will drop her FiO2 a bit to bring her sats to 93% and then go gather the stuff for an ABG radial stab. We will let her rest for a few more minutes and then I will do a gas.” Herman adjusts the FiO2 while keeping an eye on the saturations displayed on the vital sign machine. He makes a couple of more adjustments and sees the sats stabilize at 93%. He gives the FiO2 to Tracie who records it in the nurses’ notes and flow sheet.


Herman leans closer in. “Linda, can you please ask your mother how that feels with the oxygen decreased a little?”


Linda smiles. “She says she’s a little better than earlier, although still short of breath.”


“Okay, that may not change very quickly. I’m going to listen to her lungs now. Is that okay?”


Linda starts to nod, then remembers. “Wait a minute, let me ask. Mom, is it okay if the doctor listens to your lungs?”


Miki rolls her eyes and answers, “Yes, of course. Isn’t that what he’s here for?” Secretly, though, she’s glad Linda confirmed with her first before consenting on her behalf.


Herman pulls his stethoscope out and systematically auscultates Ms. Huang’s chest. “Not too bad. A bit decreased to the bases with coarse sounds and no wheezes.”


Traci smiles at Gladys. “That does sound better than what I heard this morning.”


Herman says, “Okay, she seems okay right now. I am going to get my stuff to do the ABG and will be back in about 10 minutes.”


Both Tracie and Gladys nods. Tracie nods towards Miki. “Linda, does your mother need anything right now?”


“No, we’ll probably just keep watching TV to be honest.”


Gladys pats her hand. “I will come back in about 30 minutes and see if she needs to be repositioned or feels strong enough to get into a chair then.”


Linda and Miki wave to both of them before focusing their attention on the TV.


Tracie and Gladys move out of the room.


“Thank you, Gladys, for your help. You did a great job in there.”


“Thanks Tracie. It was really nice to see that I made a difference. I’m going to talk with my preceptor about what I did and see another patient. I will come back in about 30 minutes to see how Ms. Huang is doing.”


“Awesome. Let me know if you need my help. I am going to see my other patients and hand out my 10am meds and antibiotics.”


Back in the room, both mother and daughter’s eyes are still fixed on the television, but Miki speaks up.


“When you were in the bathroom, and they came in to move me I was a little scared.”


“I’m sorry, but you really cannot expect me to be here 24/7. That’s just not possible.”


“I know, I’m not blaming you. I just wish I could have known what was going on and what they wanted to do to me.”


Linda sighs, “I’m sorry Mom. I don’t know what to say. You’ll be better soon enough, and we can get out of this place.”


Miki finds it hard to express her frustration; as kind and sympathetic as her daughter tried to be, there was just know way to truly know how frightening it was to be so physically vulnerable in an environment where you also could not understand a single word.


Across the room in her chair, all Linda wants to do is lock herself in her room and sob. It pains her to see her mother so on edge and anxious, but ever since her mother got sick Linda has constantly been feeling suffocating pressure. Besides constantly being by her mother’s side and acting as the primary liaison, she also hasn’t slept well in days and is worried about all the work she’s missing. Deep in her heart, she knows that this is not a sustainable arrangement and wonders if she made the wrong call in turning down the designated translator. Although there are so many things happening at once, the only thing Linda can’t stop obsessing over is the fact that she is almost out of allotted sick days for her job.

Time: 10h00

Herman comes up to the desk and sees Tracie charting. “Hi Tracie, I’ve done the ABG on Ms. Huang and have sent it to the lab. We should be getting the results in about 30 minutes or less. I’m going to see a patient on the tenth floor. I will check the system for the results, and I may come back and make additional changes to her FiO2.”


“Thank you, Herman. I really appreciate your help.”

Time: 11h00

Tracie logs into the clinical system in the hallway outside Miki’s room. “Okay, let’s find the ABG result. Wow, that ABG result looks much better, O2 and sats better, CO2 is high but looks normal for her. Nice. Looks like Herman can bring her FiO2 down.” Next Tracie checks to see if the culture and sensitivity is back. “C&S is still pending. Gram stain shows gram positive cocci. Okay, not sure what that means; I will have to ask Dr. Hunicutt.”


Tracie signs off the system, turns around, and runs directly into Herman. “Oh, I am so sorry!”


“No problem. Did you see the ABG result?”


“Yes, it looks better than it did even in Emergency.”


“Yes, it is, but you have to remember she is on a higher amount of O2.”


“Yes, I never considered that. Good point.”


“I am going to go in and adjust her FiO2 down a bit more. If she continues to improve, we can probably move her later today or tomorrow to Optiflow again.”


“Excellent. I will come in with you and do a focus assessment.”


“Sure, no problem.”


Both Herman and Tracie enter Miki’s room to find her and Linda still watching TV intently.


Miki notices the two of them entering her room out of the corner of her eye and groans inwardly. “Ugh, they literally just left. What do these two want again? Will I never get peace and quiet?”


“Hi, Ms. Huang. Herman here is going to make some adjustments to your oxygen level. And with the test we did earlier, we may be able to move you to a more comfortable type of mask.”


Tracie moves the vital sign machine to Miki’s bedside and attaches it to her left arm and right finger.


Herman checks the pulse ox saturation and then begins to adjust the FiO2. He thinks, “It’s not below the toxic level of oxygen, which should help.”


The oxygen saturation stays stable. Tracie listens to Miki’s chest and finds that the air entry is decreased to her bases, with a few crackles, and no wheezes noted. Vital signs are unchanged from the morning.


“You are looking pretty good, Ms. Huang.”


Linda jabs her mom excitedly, “Hey, they said you’re looking pretty good!”


Miki rolled her eyes. “Then why am I still here? Tell them not to waste their time lying to me and heal me instead.”


Linda smiles at the doctors, “Um, my mom said thanks.”


Herman smiles back. “Dr. Hunicutt will also be coming by today to update you>”


“Okay Tracie, I have decreased the FiO2 below .50 and she looks to be holding her saturations really well at 93%. I will come by towards the end of the shift and if things are good, move to Optiflow.”


“Thanks, Herman.”


Just then, Gladys enters the room. “Hi Tracie. Hi Ms. Huang and Linda! Would you like to sit in a chair or move to a different position?”


Linda translates, then turns to Gladys, “She said a chair sounds much better.”


Gladys then directs both Tracie and Herman to assist her to move Miki to a bedside chair. Miki transfers easily and feels much more comfortable.


Gladys explains, “We need to be careful that you do not get any bed sores. Plus, moving around helps your lungs out. Tomorrow I will come by and get you walking the hallways.”


Suddenly more cheerful, Linda is pleased with the progress and the prospect of her mother moving around. She thinks that perhaps she should run home later and grab her laptop so she can get some work done when her mom’s walking tomorrow.


Tracie leans forward and adjusts the blanket on Miki. “All good. Need anything right now?”


Linda asks her mom, who shakes her head. Tracie heads to the nursing station to complete her charting, and Gladys heads off to find her preceptor.

Time: 19h00-shift change

“Hi Jim, how are you this lovely evening?”


“Hi Tracie, I am doing well. I had a great sleep.”


“Awesome. You should have the same patients as last night.”


“Cool. Should be a quick report.”


Tracie then describes the status of each of the patients. Coming to Miki’s chart, Tracie explains, “Ms. Huang is doing much better, up in a chair today. Deep breathing exercises cleared a lot of sputum. FiO2 less than .5 gram stain came back gram positive, but Dr. Hunicutt says it is not too helpful for adjusting her antibiotics. C&S should be available tomorrow. The RT did not want to move quite yet to Optiflow and they may do so tomorrow. She is still comfortable on the mask, and the humidity may help clear secretions.” Tracie then goes through the rest of the assessment.


“Looks good, thanks, Tracie. I guess tomorrow is your last day shift?”


“Yes, see you in the morning.”


This section has been from Health Case Studies by Glynda Rees, Rob Kruger, and Janet Morrison.


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Pathology Copyright © 2022 by Annabelle Liao is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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