Lillian Brown is an 80-year-old widow who lives in an older adult community. She lives alone and is independent in her daily activities, including driving. Her 55-year-old daughter lives nearby, phones daily, and visits frequently. Lillian has been remarkably healthy over the years despite her smoking for 60 years. She has a history of COPD for the last 10 years and continues to smoke approximately one half a pack a day. She uses albuterol for her COPD when she feels the need despite her physician’s instructions to use it as prescribed.
Lillian had complained that she felt flu-like yesterday. Although her daughter was concerned, Lillian had promised to call her physician in the morning. When her daughter called today, Lillian was extremely confused. Being very concerned, her daughter drove to Lillian’s house and found her sitting on the couch coughing with the chills and confused. Her daughter drove her to the local hospital emergency department where the physician performed a physical exam.

Significant findings from the physician’s exam results were as follows.
Vital Signs: B/P 130/84, P 112 and irregular, T 39 C, R 24, O2 Saturation 82% on room air. Height = 5 ft 5 in. Weight = 52 kg.

Skin: Warm, clammy.

Lungs: Breathing labored with tachypnea. The right lung field is clear to auscultation with diminished breath sounds throughout both lung fields. Her left lower lung field is absent of breath sounds and dull to percussion.

Cardiovascular: Heart tones are tachycardic with irregular rhythm.
Neuro: Alert, oriented x 1; to person only. Responds to her name.
The physician ordered blood work, urinalysis, sputum for gram stain, sputum cultures, EKG, and a chest X-ray.

Significant findings

White blood cell count (WBC) of 7.7 is within normal limits (WNL).
Chest X-ray showed consolidation of the inferior segment of the left lower lung with remainder of the lung fields clear. The heart size was within normal limits (WNL).
Sputum gram stain showed gram + cocci in chains and pairs.
Urinalysis was WNL.
EKG showed atrial fibrillation.

Diagnosis: LLL community acquired pneumonia and possible MRSA (methicillin resistant staph aureus). Hypoxemia. Chronic atrial fibrillation.

Physician orders

O2 at 2L per Nasal Cannula
Start an IV with 1,000 ml D5NS to infuse over 12 hours
Blood cultures x 3 15 minutes apart
Imipenem/cilastatin 500 mg every 6 hours IVPB
Admit to Medical-Surgical floor
Call Dr. J when admitted to the floor for further orders

Questions based on information provided

1. In which order will the nurse carry out the IV fluid, IV antibiotic, and blood culture physician’s orders? State the rationale for your prioritization.

2. How many ml an hour of the IV fluid will Lillian receive, and how many ml and hour will the nurse set the IV pump to deliver per hour? Show your work or explain how you got your answer.

3. Describe how Imipenem/cilastatin works in the body. Be sure to include drug category, mechanism of action, onset and duration of action, and safety consideration.

Class,
To do this correctly, Review the case study and answer all three questions that are listed. Be cautious not to wear blinders. You need to consider all of the pertinent assessment data in this scenario. For example, isn’t it important that Lillian has atrial fibrillation? What happens to the heart and entire system when someone has this arrhythmia? (just one page)