4.1.3: FRAME 3- Prioritize Hypothesis

It has been 4 hours since the nurse sent down the sputum culture, and Stanley’s labs were drawn from the phlebotomist. Stanley’s call light comes on, and the nurse responds. Upon arrival into Stanley’s room, the nurse sees Stanley sitting on the side of his bed, leaning over the bedside table, and water spilled on the floor. Stanley is severely dyspneic and tells the nurse, “I’m sorry…” (gasp for breath) “I spilled….” (gasp for breath) “my water.” The nurse recognizes a decline in Stanley and looks at the continuous pulse ox machine, which reads 84%.

Prioritize Hypotheses

QUESTION: Bow-tie Scoring Rule: 0/1

It is important for the nurse to quickly identify what condition Stanley is most likely experiencing. Complete the diagram below by selecting the condition the client is most likely experiencing, three actions the nurse should take, and three parameters the nurse should monitor to assess the client’s progress.

Actions To Take	Which Condition is the Client Most Likely Experiencing?	Parameters To Monitor
Lay the client down and prop pillows behind him so he is laying on his left side	COPD exacerbation	Pulse oximetry
Prepare to administer an air entrainment mask	Worsening Pneumonia	Client’s respiratory patterns
Provide a calming atmosphere	Pulmonary Embolism	Vital signs
Take the client’s temperature	Asthma attack	Client’s fever
Call the provider	Cor pulmonale	Client’s ability to drink fluids
Complete a full head-to-toe assessment		Activity tolerance

Putting It All Together

DEBRIEF

Stanley is experiencing a COPD exacerbation. This is evident by the decreased pulse oximetry, dyspnea, and use of accessory muscles. It is essential for the nurse to quickly evaluate and hypothesize appropriate action. Recognizing a decline in the client’s condition requires the nurse to call the primary provider to update them on the status change.

The nurse will anticipate the provider ordering a different kind of oxygen delivery therapy, including an air-entrainment (venturi) mask. This oxygen device allows the healthcare provider to provide an exact FiO2. When administering oxygen to clients with COPD, the nurse should start with the lowest FiO2 to maintain adequate oxygenation and titrate it based on the client’s response. Additionally, the nurse will want to maintain a calm atmosphere to reduce anxiety in the client. The nurse may call an unlicensed assistant personnel (UAP) into the room to assist. Increased anxiety in the client may worsen their respiratory patterns, further exacerbating the problem.

Laying the client down on his left side is not an optimal position and may cause a further decline in the client’s oxygenation status. Client’s that are experiencing respiratory complications should be sat up to allow expansion of the rib cage. Completing a full head-to-toe assessment and taking the client’s temperature are not the priority actions for a client with a declining respiratory status.

RECOGNIZING SOCIAL DETERMINANTS OF HEALTH (SDOH)

The second SDOH domain addressed in this case study is Health Care Access & Quality. About one in ten people in the United States do not have health insurance. Individuals without health insurance are less likely to have a primary care provider and may not be able to afford health care services or medications needed. Recognizing COPD and other respiratory diseases impact clients beyond dyspnea and increasing the proportion of clients who understand their health information is more likely to lead to better health outcomes.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) is a collaboration of healthcare professionals and public health officials from around the world that work together to provide evidence-based treatments in the management of COPD and raise awareness to improve, prevent, and treat lung disease (GOLD, 2022). Providing guidelines that include outpatient and inpatient care strategies to reduce respiratory exacerbations and improve clients’ quality of life is a primary example of increasing healthcare quality. Improving healthcare communication (HC/HIT-02) and client understanding (HC/HIT-01) are both objectives of the Health Care Access & Quality domain.

What Do You Think About?

1. What actions and/or assessment pieces would indicate the client is continuing to decline?
2. Who might the nurse also include in the care of the client? What other healthcare professionals would be beneficial in providing holistic care?
3. Relate Stanley’s confirmed pneumonia infection with his current COPD exacerbation.