Appendices: Case study for Pneumonia
Place: Medical Unit
Tracie walks into the nursing station and heads to her usual chair. She moves the assignment book towards her and sees that she has the same assignment as yesterday. “That’s okay,” she thinks, “At least I know the patients.” She looks up at the patient board and sees that there have only been two admissions since yesterday and one discharge. “Looks like it could be a busy discharge and admissions day.”
Jim comes down and pulls his chair close to Tracie’s. “Hi Tracie, how’s it going?”
“So far so good, how was your night?”
“Night was quiet. Ms. Huang required some adjustments in her Optiflow which the RTs took care of. Mr. Alex had a bit of sundowner syndrome and was quite restless, but otherwise the night was pretty quiet.”
“Great. Okay, let’s do the report so you can get home.”
“Yeah, I have to get out of here quick. I’m taking the kids on a field trip later in the afternoon. Twenty-six Grade 2 kids. I can’t believe I volunteered to chaperone after a night shift.”
Tracie laughs, “Lucky you.”
Jim then walks Tracie through the night and updates her on changes to her patients. After reporting, Jim heads out, while Tracie quickly looks through the charts to plan her morning. Tracie notes that she has a lot of 08h00 medications so she decides to prepare these meds and then do her patient checks at the same time.
Tracie makes her rounds and drops off all her medications. With that done, she notes to herself, “Everyone seems all right now, having breakfast. I didn’t see any issues off the top. I’ll give everyone a few minutes and then do vitals, assessments, and discharges.”
Tracie sits down to check the RT’s note on Miki Huang when Miki’s call bell rings. She gets up from her chair and walks down the hallway to her room.
“Hi, Ms. Huang. Hi Linda. How can I help?” She notices Linda’s disheveled appearance and dark moons under her eyes with slight concern.
Linda herself is frantic. “My mother said she couldn’t catch her breath shortly after we took off her oxygen to eat. Can you help us put it back on please?”
“I want Miki to take some deep breaths. Tell her in through her nose and out her mouth. Remember to close the lips slightly as she breathes out. I’m going to get the vitals machine and be right back.”
Miki watches Tracie walk briskly out of the room and is annoyed. What good is she if she’s not going to help? She then hears her daughter speaking to her and turns around to realize that she’s telling her how to breathe. “What’s the point of staying in the hospital if I’m just going to breathe on my own without the oxygen?” She thinks to herself. “I can literally do this at home.”
Miki reluctantly follows Linda’s instructions and continues to take deep breaths, although she makes it a point to glare at her daughter throughout the entire process. Linda, weary and frustrated herself, glares back.
Tracie grabs a vital signs machine from the hallway charger and brings it into Miki’s room to take her vital signs.
“Okay, let’s start checking you out.” Tracie wraps the blood pressure cuff around Miki’s left arm, pulse oximeter on the right forefinger, and temperature probe under the tongue. About 30 seconds later, she notes that the blood pressure is up a bit, and the oxygen saturation is down. Temperature is unchanged with the same low-grade fever. Respiratory rate is up as well, and heart rate is above 110 bpm. “This is not going in the right direction,” she thinks, “I may need the RT to come see her.”
|Day: 2||Pulse Rate||Blood Pressure||Respiratory Rate||Temperature||O2 Saturation|
|Time: 07h30||112||165/90||22||36.5°C||83% on RA|
“Okay, Ms. Huang, let’s listen to your heart and lungs.”
Tracie systematically auscultates, thinking, “Not any change from what I remember yesterday.”
“How are you feeling now?”
Linda conveys the question to her mother, who answers: “Not great, but maybe a bit better.”
“Alright, I’m going to ask the RT to come and see you right away.”
Linda instantly becomes alert. “Why? Is she okay? Is she…dying?”
“Gosh no, Linda. The respiratory therapist is here to help both your mother and me. They manage the oxygen and help with breathing.”
“Oh,” Linda replies. “Good.”
“I will be right back.” Tracie moves quickly again out to the main hallway to the nursing station. She then asks for the RT to be paged and to come to Miki Huang’s room.
The unit coordinator looks up. “What should I tell them.”
“Ms. Huang is quite short of breath and has low sats on Optiflow. I’m not sure what to do next.”
“Done. If they have any further questions, I’ll transfer their call to the phone outside the room.”
Tracie heads back to Miki’s room.
Tracie has the vitals machine to another cycle of vital signs but not the temperature. She reads the machine, thinking, “Heart rate is down to slightly less than 100 bpm. Respiratory rate is still up and sats have only improved slightly.” Tracie records all this information and her assessment into Miki’s chart. Just then, Alexa, the RT, enters the room.
|Day: 2||Pulse Rate||Blood Pressure||Respiratory Rate||Temperature||O2 Saturation|
|Time: 07h45||98||165/90||22||–||85% on Optiflow|
“Yes, you remembered! So, you must also remember Ms. Huang then. And her daughter too?”
“Yes, I do. Have her sats not improved? You asked her to breathe deep like yesterday?”
“Yes. She has improved slightly but not very much with the deep breathing.”
“Okay, let’s take a look. Hi Ms. Huang and Linda, do you remember me?”
Linda, too tired to process, stares back. Miki, obviously not understanding, also stares back.
Alexa chuckles awkwardly. “I was in Emergency yesterday. Anyways, I’m going to listen to your chest and then I may have to take some blood from your wrist again.”
Linda snaps out of it and tells her mother that they’re going to check up on her again, and Miki nods solemnly. Alexa methodically assesses Miki’s respiratory system.
“Okay, Ms. Huang. Your breath sounds don’t seem much different than they did in Emergency, but obviously you are not feeling your best. I think I am going to have to change your oxygen treatment to a face mask. Have you had a face mask before?”
Linda shakes her head, “I don’t think so.”
“It’s a mask that covers both your mouth and nose. It allows me to give you a bit more oxygen than the system you are currently on. I am going to get the equipment to do so, and we will see how you do with the new oxygen treatment and whether you need another needle poke in your wrist.”
Alexa steps out to the storeroom and selects a high flow mask with humidifier. Back in Miki’s room, she sets up the equipment and turns the flow meter up as high as it goes. Looking at the humidifier bottle, Alexa notes a good amount of bubbling.
“Ms. Huang, I’m going to take away those nasal prongs and place a mask on your face.”
Before Linda can translate, Alexa confidently changes the therapy and places the high flow mask on Miki.
“Now, take some deep breaths slowly and blow out through your mouth. How does that feel now?”
Miki turns to Linda, “Well at least I don’t think I’m going to die anymore,” she says sarcastically.
Linda sighs. “She says she feels a bit better, thanks.”
Turning to Tracie, Alexa states: “I have placed her on 65Fi02 high flow face mask. Can you do another set of vitals for me?” Tracie hits start on the vitals machine.
Both health professionals, along with Miki, and Linda, turn to look at the numbers as they appear on the screen.
|Day: 2||Pulse Rate||Blood Pressure||Respiratory Rate||Temperature||O2 Saturation|
|Time: 08h05||98||165/90||22||–||092% on High Flow FM|
“Okay, Ms. Huang, your oxygen level is better, and your other vitals look the same as they did when I first came on shift. I have another patient to see next door, but before I leave, I will come back and see how Ms. Huang is doing.”
Tracie nods and follows Alexa out of the room. “What do you think is going on? Why did her saturations drop, Alexa?”
“Her pneumonia might be progressing a bit. Sometimes that happens even with antibiotics. Antibiotics take about three days to really work well. In the meantime, if she could stand it, we should see if Physio can see her and maybe get her moving, which will help with chest expansion. One of the worst things to do is just lie about. Is she due for a Chest X-ray (CXR)?”
“Yes, I saw that she will be getting one around 2pm this afternoon. Can she go down with that mask on?”
“No problem. I will make sure that there is a full tank available. Tony is the RT in Emergency and he also covers X-ray if need be. I will let him know in case there is an issue while she is down there.”
“Okay, I will talk with the doctor about a physio order and let him know you have adjusted her O2.”
“Thanks. I will look in on her after I see my other patients on this floor. If her sats stay up where they are, I don’t believe she needs a blood gas.”
“Awesome. Okay, see you later.”
“Hi Dr. Hunicutt, I’m Tracie. One of my patients, Miki Huang, is under your care.”
“Aw, yes, the older lady with COPD and pneumonia. How was her night?”
“Night was pretty good, needed some adjustment on her Optiflow but otherwise slept well. My concern is what happened this morning. She became quite short of breath and anxious; I called the RT, and we made some adjustments and moved her to high flow face mask at .65. Sats responded and she improved to 93% and has stayed there for the past hour. Appears quite relaxed now. No other changes in breath sounds or temperature. Very little sputum production.”
“Very good. Let’s go and see her now and see if I need to make any further adjustments.”
Both Tracie and Dr. Hunicutt walk down the hall to Miki’s room. As they enter, they see Miki sitting in bed with a green oxygen mask on, flicking through the TV channels. Linda is also sitting in the corner of the room, eyes fixed on the TV and occasionally making comments on the programs.
Linda notices the pair enter the room and immediately stands up out of formality. “HiI everyone. My mother keeps complaining about the mask blocking her view. Do you know how much longer she needs to keep it on for?”
“Hi Ms. Huang, and you must be her daughter. My name is Dr. Hunicutt, and I am a doctor helping to care for you. I see you are less short of breath right now. Would you mind if I listen to your chest?”
He gestured towards Miki as he spoke, and Miki, understanding, nodded but sighed.
Dr. Hunicutt takes his stethoscope out and systematically listens to Miki’s heart and lungs. Then he proceeds to examine the rest of Miki.
“Very good. Thank you, Ms. Huang.”
“It can’t be too good, otherwise we wouldn’t be stuck here,” Linda muttered under her breath.
“My apologies. It is okay. Your mother’s lungs are not the healthiest due to the COPD, and by listening to your chest I can see that she does have lots of consolidation in both lower lobes.” Dr. Hunicutt points to where he heard the bronchial breath sounds.
Linda’s face flushes red. “I’m so sorry, doc. I didn’t know you would hear what I just said. I don’t know what came over me, I’m just so tired.”
“It’s okay, Linda, I understand. I do believe that Miki is on the right antibiotics. We are still waiting for the sputum test to tell me that, and we will also do a chest X-ray today to confirm that the pneumonia is not spreading more. Tracie, is there anything you would like to add?”
“I would like to have Physio come over to see her and get her moving a bit more.”
“I think that is a very good idea. I will write the order. They may not come today, but that doesn’t mean Ms. Huang cannot sit in a chair or stand at the bedside. I don’t want her doing too much, but she does need to move a bit more.”
“We can do the chair. What about the bathroom?”
“Commode at bedside until she is below 50% oxygen. Anything else?”
“Alexa the RT said she would wait to do another blood gas as her sats are okay right now.”
“I agree. But I will write an order for another blood gas tomorrow morning to see how we stand with CO2 and PaO2. I want to ensure that her COPD does not get worse as well. At this point, our other option is BiPAP (a non-invasive ventilation device which applies different levels of positive pressure in the airways during inhalation and exhalation to allow for easier ventilation), which I’m pretty sure Ms. Huang will not be happy with, so let’s see if we can manage her without going to intensive care.”
“Thank you. I think that will do. Ms. Huang and Linda, do you have any questions?”
“No, I think we’re good for now,” Linda answers. Miki, who hadn’t been translated for this entire time, remains silent. She was trying hard not to be irritated as she knew that her daughter was already trying her best, but it was not easy constantly being out of the loop especially when she was the topic of discussion.
Both Dr. Hunicutt and Tracie smile, nod at the mother-daughter duo, and then leave the room.
Outside the room, Dr. Hunicutt asks if anything else needs to be done. Tracie points to a couple of other rooms where she has patients and explains that two patients need discharge orders, and two others need lab work looked at, as pharmacy is stating that antibiotic coverage may not be appropriate. Dr. Hunicutt nods his head and gives her the thumbs up sign as he heads to the chart rack to begin the process of discharge and looking at labs.
Tracie begins the process of recording the interaction with Dr. Hunicutt and Miki, making sure to include Linda’s role and presence.
Over the course of the day, Tracie was able to get Miki up twice to the bedside commode and twice to a chair for 30 minutes each time. Miki’s saturation stayed stable along with her other vitals signs.
When the shift change rolled around, Tracie was very happy to see Jim come into the unit. “Wow, I did not think I would see you tonight.”
“Me either. They called me for overtime during my chaperoning of a school trip.”
“Man, you must be exhausted.”
“Yeah, but no more than usual. Got some shuteye before coming in. Anyway, how was your day?”
Tracie gives an overall report of two discharges and two new admissions. She updates Jim on changes to Miki’s oxygen levels and her increased orders for activity.
“Awesome, thanks. Will I see you in the morning?”
“I believe you will. I’m doing four days in a row. I traded my night shifts so I could attend a play with my husband. We have had so little time together with him finishing his PhD, and my shift work. He promised not to talk research and take me out on a real date if I would change my night shifts.”
“Wow, I am so jealous. Well, have a good sleep and we will see you in the morning.”
While this exchange was happening, Miki and Linda are having their own conversation, or rather, altercation, back in the room.
“What’s the point of having you here if you’re not going to tell me anything they’re saying?” Miki says in an accusatory tone.
Linda throws up her hands, “I don’t know what you want me to say! You can’t actually expect me to translate word for word every single thing that’s going on. It’s too much, you should know that.”
“The very least you could do is not act like I’m not even here. Would an actual translator do that?”
“Maybe we should just get you an actual translator then. You think I’m having fun right now?” Linda snaps back. “I have missed how many days of work now and you haven’t even uttered a single ‘thank you’.”
“Works for me. At least an actual translator wouldn’t consent to things on my behalf without consulting me first.” Miki answers scornfully.
“That wasn’t even that big of a deal!” Linda cries out. “That was literally just to take your blood. If you want to be involved so bad, maybe you should’ve learned English then!”
Taken aback by the volume of her normally quiet daughter’s voice, Miki pauses. “I don’t know. I’m sorry. Everything is just so different here, but I know how tired you must be. I miss home.”
Somehow, Linda knew that the home her mother was referring to was Taiwan and not their townhouse a few blocks away. “I’m sorry too. I shouldn’t have said that. I know you’re doing your best to adjust to this new environment. I’ll try to keep you in the loop more from now on. Say, even the food is making it difficult, huh?”
Miki cracked a small smile. “Oh god. What is it with these people and their Jell-O. Don’t they know the perfect desserts shouldn’t be too sweet?”
Smiling herself, Linda reaches out to pat her mother’s wrinkled hand. “Don’t worry, Mom, we’ll be home before you know it.”
This section has been from Health Case Studies by Glynda Rees, Rob Kruger, and Janet Morrison.