ANS1.

THE IMPORTANCE OF TPAPN CASEPRESENTATION IN NURSING

A case presentation is a formal communication between health care professionals (doctors,

pharmacists, nurses, therapists, nutritionist etc.) regarding a patient's clinical information. The Texas
Nursing Practice Act requires employers (and peers) to report nurses who are impaired, or
suspected of being impaired, by chemical dependency or diminished mental capacity.

1. If the impaired nurse is believed to have committed a Nursing Practice Act violation, the nurse
must be reported to the BON.
2. If no Nursing Practice Act violation occurred, the nurse must be reported to either TPAPN, to
a nursing peer review committee (if available), or to the BON.

.
case presentations are an important component of the nurse practitioner’s skills, yet very few little
literature exists to guide the development of this skill, and frequently little priority is given to teaching
this skill during the education of the nurse practitioner. The importance of effective case
presentations, describes the organization of the presentation, and outlines the appropriate information
to be included. The main components of a case presentation—introduction, history of the present
illness, physical examination, diagnostic studies, differential diagnosis, management, and summary of
the case—are discussed in detail. ITS MAIN ADVANTAGES ARE ;
To improve the clinical reasoning processes of the presenter, the short presentation has several
advantages: (1) shortening the presentation requires abstraction of information, possibly leading to
better problem representation;
(2) it is time-efficient;
(3) it stimulates more informal interactions with the facilitator and the audience. In clinical settings, a
presenter uses his/her time for the preparation of case presentations to reflect on the information
he/she has collected. The facilitator should know how to improve case presentations to diagnose and
improve the presenter.

ANS2. HERE I M PRESENTING A CASE PRESENTATION WHICH INCLUDE NURSI NG CARE

PLAN AND ITS OUTCOME TOO :

CASE PRESENTATION
A 45-year-old man  Ms. Ronak presented to the emergency department complaining of persistent
right-sided chest pain and cough. The chest pain was pleuritic in nature and had been present for the
last month. The associated cough was productive of yellow sputum without hemoptysis
.
PAST MEDICAL HISTORY: He had unintentionally lost approximately 30 pounds over the last 6
months and had nightly sweats. He had denied fevers, chills, myalgias or vomiting. He also denied
sick contacts or a recent travel history. He recalled childhood exposures to persons afflicted with
tuberculosis.
 
The client's past medical history was remarkable for chronic "shakes" of the upper extremities for
which he had not sought medical attention. Other than daily multivitamin tablets, he took no regular
medications. 

PERSONAL/SOCIAL HISTORY:
Ronak is a widow for the past 2 year , after being married for 10 years and is currently living with his
son . Worked as private sector service man and served many hospital he is a nurse working in
Bandjohn hospital and get addicted to substance abuse. 
The client smoked one pack of cigarettes daily for the past 10 years and accepted to cocaine and
weed recreational drug use. He reported ingesting twelve beers daily and had had delirium tremens,
remote right-sided rib fractures and a wrist fracture as a result of alcohol consumption. He had worked
in the steel mills but had discontinued a few years previously. He collected coins and cleaned them
with mercury. 

Hospital course 
He was initially admitted to the general medical floor for treatment of community-acquired pneumonia
and for the prevention of delirium tremens. He was initiated on ceftriaxone, azithromycin, thiamine and
folic acid. Diazepam was initiated and titrated using the Clinical Institute Withdrawal Assessment for
Alcohol Scale , a measure of withdrawal severity (1).  By hospital day 5, his respiratory status
continued to worsen, requiring transfer to the intensive care unit (ICU) for hypoxemic respiratory
failure. His neurologic status had also significantly deteriorated with worsening confusion, memory
loss, drowsiness, visual hallucinations (client started seeing worms) and worsening upper extremity
tremors without generalized tremulousness despite receiving increased doses of benzodiazepines.
 
Physical Examination
On arrival at the medical ICU, the client appeared cachectic and dyspneic. He was unable to complete
sentences. His blood pressure was 125/71 mm Hg, heart rate of 122/min, temperature 100 °F,
respiratory rate 33/min, and oxygen saturation 77% on room air and 92% on 40% venti-mask. At the
time of presentation to the hospital he had oxygen saturation of 92% on room air.  The heart exam
revealed tachycardia but regular rhythm, a normal S1 and S2 and no murmurs, gallops or rubs. On
auscultation of the lung fields, breath sounds were diminished on the right side in the upper zone
without the presence of adventitious sounds. The abdomen was benign without organomegaly. The
client's extremities were normal with absence of clubbing or edema. He was oriented only to person,
and had an inability to pay attention or remember immediate events. He was moving all four
extremities with slightly brisk deep tendon reflexes. Neck was supple and the pupils were brisk in
reacting to light.
 
Current vital sign 
Current vital signs T: 103.2F/39.6, P 117regular, R 35 labored and using accessory muscles, BP
180/96, O2 sat 82% on 6 liters of oxygen via nasal cannula, P-Q-R-S-T Pain Assessment Provoking:
deep and shallow breathing, Quality: ache, Radiation: generalized pain over right side of chest no
radiation, Severity: 3/10, Timing: Intermittent last a few seconds
 
General Appearance: appears anxious and in distress
,with normal chest
Respiratory: Dyspnea with use of accessory muscles, breath sounds very diminished bilaterally
anterior and posterior
Cardiac: Pale hot and dry, no edema, heart sounds regular S1 S2 pulse strong equal with palpation at
radial/pedal/post-tibial landmarks.
Neuro: Alert and orientated to person, place, time, and situation (x4)
GI: Abdomen soft nontender bowel sounds audible per auscultation in all 4 quadrants
GU: Voiding without difficulty, urine clear
Skin: intact turgor elastic and no tenting visible
 
 Laboratory diagnostic investigations :
White blood cell count was 11,000/mm3 with 38% neutrophils, 8% lymphocytes, 18 % monocytes and
35% bands
Haematocrit 33%
Platelet count was 187,000/mm3
Serum sodium was 125 mmol/L, potassium 3 mmol/L, chloride 91 mmol/L, bicarbonate 21 mmol/L,
blood urea nitrogen 14 mg /dl, serum creatinine  0.6 mg/dl and anion gap of 14.
Urine sodium <10 mmol/L, urine osmolality 630 mosm/kg
Liver function tests revealed albumin 2.1 with total protein 4.6, normal total bilirubin, aspartate
transaminase (AST) 49, Alanine transaminase (ALT) 19 and alkaline phosphatase 47.
Three sputum samples were negative for acid-fast bacilli (AFB).
Bronchoalveolar lavage (BAL) white blood cell count 28 cells/µl, red blood cell count 51 cells/µl,
negative for AFB and negative Legionella culture.  BAL gram stain was without organisms or
polymorphonuclear leukocytes.
Blood cultures were negative for growth.
Sputum cultures showed moderate growth of Pasteurella multocida.
2D transthoracic ECHO of the heart showed normal valves and an ejection fraction of 65% with a
normal left ventricular end-diastolic pressure and normal left atrial size.  No vegetations were noted.
Purified protein derivative (PPD) administered via Mantoux testing was 8 mm in size at 72 hr after
placement.
Human immunodeficiency virus (HIV) serology was negative. 
Arterial blood gas (ABG) analysis performed on room air on presentation to the ICU: pH 7.49,
PaCO2 29 mm Hg, PaO2 49 mm Hg.
Figures

Figure 1. Chest radiograph at the time of initial presentation.

 
Chest radiograph at the time of shifting ICU

TREATMENT
CLIENT IS ON: 
AUGMENTIN 625MG OD 
PANTAPRAZOLE INJECTION 40 MG BD 
NEBULIZATION WITH DUOLIN AND BUDECORT TDS I RESPULE EACH 
TAB DOLO 650MG TDS 
TAB ASPIRIN 75MG OD 
TAB ATORVASTATIN 200MG OD 
FLUID NS 0.45% 40ML/HOUR 
 

Assessment data
Inspection :        anterior posterior ratio 1: 2 with no barrel chest and normal symmetry 
Dysponea with use of accessory muscle( Accessory muscles, such as the                  
sternocleidomastoid and the scalene muscles) .
                             Breath are shallow, deep or normal and, again
                             increased pulmonary secretions
                           airway not patent filled with secretions .
             
Palpation   :     no palpable lymphnode seen on neck 
                            No tenderness 
 Percussion :       no pleural effusion seen 
                               Mucus accumulation in lungs 
Auscultation:        dimished breadth sound bilaterally anteriorly and posteriorly.
                                 No irregular herat sound audible 
                                 S1& S2 SOUNDS are regular and audible too.
 
DETAILED ASESSMENT 
1. Assess and record respiratory rate and depth at least every 4 hours.
The average rate of respiration for adults is 10 to 20 breaths per minute. It is important to take action
when there is an alteration in breathing patterns to detect early signs of compromise on
the respiratory system.
2. Assess ABG levels according to facility policy.
This monitors oxygenation and ventilation status. See our Tic-Tac-Toe guide on analyzing ABGs
3. Observe breathing patterns.
Unusual breathing patterns may imply an underlying disease process or dysfunction. Cheyne-Stokes
respiration signifies bilateral dysfunction in the deep cerebral or diencephalon related to brain injury or
metabolic abnormalities. Apneusis and ataxic breathing are related to the failure of the respiratory
centers in the pons and medulla. Rates and depths of breathing patterns include:

 Apnea
Temporary cessation of breathing, especially during sleep
 Apneusis
Deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient
release
 Ataxic patterns
Complete irregularity of breathing with irregular pauses and increasing periods of apnea
 Biot's respiration
Groups of quick, shallow inspirations followed by regular or irregular periods of apnea (10 to
60 seconds).
 Bradypnea
Respirations fall below 12 breaths per minute, depending on the age of the client.
  Cheyne-Stokes respiration
Progressively deeper and sometimes faster breathing, followed by a gradual decrease that
results in apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes.
 Eupnea
Normal, good, unlabored ventilation, sometimes known as quiet breathing or resting,
respiratory rate
 Hyperventilation
Increased rate and depth of breathing
 Kussmaul's respirations
Deep respirations with fast, normal, or slow rate associated with severe metabolic acidosis,
particularly diabetic ketoacidosis (DKA) but also kidney failure
 Tachypnea
Rapid, shallow breathing, with more than 24 breaths per minute

4. Auscultate breath sounds at least every 4 hours.

This is to detect decreased or adventitious breath sounds. Abnormal breath sounds may include:

 Bronchospasm
Constant breath sounds of both rhonchi and wheezing; normally treated with a bronchodilator.
 Expiratory grunt
Frequently occurs in combination with nasal flaring and intercostal or subcostal retractions,
associated with increased work of breathing.
 Rales
Clicking, rattling, or crackling sounds are heard during inspiration and expiration.
 Rhonchi
Coarse crackle sound that is wetter than a rale. Suctioning recommended.
 Stridor
High-pitched, musical breathing sound caused by a blockage in the throat or voice box
(larynx).
 Wheeze
High-pitched, whistling sound when air moves through narrowed breathing tubes in the lungs.
This is heard most commonly in asthmatics and CHF

5. Ask if they are "short of breath" and note any dyspnea.

Sometimes anxiety can cause dyspnea, so watch the client for "air hunger," which is a sign that the
cause of shortness of breath is physical.
6. Assess for the use of accessory muscle.
Work of breathing increases greatly as lung compliance decreases.
7. Monitor for diaphragmatic muscle fatigue or weakness (paradoxical motion).
Paradoxical movement of the abdomen (an inward versus outward movement during inspiration) is
indicative of respiratory muscle fatigue and weakness.
8. Observe for retractions or flaring of nostrils.
These signs signify an increase in respiratory effort.
9. Assess the position that the client assumes for breathing.
Orthopnea is associated with breathing difficulty.
10. Utilize pulse oximetry to check oxygen saturation and pulse rate.
Pulse oximetry is a helpful tool to detect alterations in oxygenation initially; but, for CO2 levels, end-
tidal CO2 monitoring or arterial blood gases (ABGs) would require obtaining.
11. Inquire about precipitating and alleviating factors.
Knowledge of these factors is useful in planning interventions to prevent or manage future episodes of
breathing problems.
12. Assess ability to mobilize secretions.
The incapability to mobilize secretions may contribute to a change in breathing patterns.
13. Observe the presence of sputum for amount, color, consistency.
These may be indicative of a cause for the alteration in breathing patterns.
 
 
PRIORITY WISE NURSING DIAGNOSIS 
 1. INEFFECTIVE BREATHING PATTERN AS RELATED TO ACCUMULATION OF
SECRETIONS AS EVIDENCE BY DYSPONEA 

 OUTCOME/GOAL: to maintain the airway patency 

 Client maintains an effective breathing pattern, as evidenced by relaxed breathing at normal

rate and depth and absence of dyspnea.
 Client's respiratory rate remains within established limits.
 Client's ABG levels return to and remain within established limits.
 Client indicates, either verbally or through behavior, feeling comfortable when breathing.
 Client reports feeling rested each day.
 Client performs diaphragmatic pursed-lip breathing.
 Client demonstrates maximum lung expansion with adequate ventilation.
 When client carries out ADLs, breathing pattern remains normal.

 
Interventions : 
1. Place client with proper body alignment for maximum breathing pattern.
A sitting position permits maximum lung excursion and chest expansion.
2. Encourage sustained deep breaths. Techniques include (1) using demonstration:
highlighting slow inhalation, holding end inspiration for a few seconds, and passive
exhalation; (2) utilizing incentive spirometer and (3) requiring the client to yawn.
These techniques promote deep inspiration, which increases oxygenation and prevents atelectasis.
Controlled breathing methods may also aid slow respirations in tachypneic clients. Prolonged
expiration prevents air trapping.
3. Encourage diaphragmatic breathing for clients with chronic disease.
This method relaxes muscles and increases the client's oxygen level.
4. Evaluate the appropriateness of inspiratory muscle training.
This training improves conscious control of respiratory muscles and inspiratory muscle strength.
5. Provide respiratory medications and oxygen, per doctor's orders.
Beta-adrenergic agonist medications relax airway smooth muscles and cause bronchodilation to open
air passages.
6. Avoid high concentrations of oxygen in clients with COPD.
Hypoxia triggers the drive to breathe in the chronic CO2 retainer client. When administering oxygen,
close monitoring is critical to avoid uncertain risings in the client's PaO2, leading to apnea.
7. Maintain a clear airway.
Encouraging the client to mobilize their own secretions via effective coughing facilitates adequate
clearance of secretions.
8. Suction secretions, as necessary.
Suctioning helps to clear the blockages in the airway.
9. Stay with the client during acute episodes of respiratory distress.
This will reduce the client's anxiety, thereby reducing oxygen demand.
10. Ambulate client as tolerated with doctor's order three times daily.
Ambulation can further break up and move secretions that block the airways.
11. Encourage frequent rest periods and teach the client to pace activity.
Extra activity can worsen shortness of breath. Ensure the client rests between strenuous activities.
12. Consult a dietitian for dietary modifications.
COPD may cause malnutrition which can affect breathing patterns. Good nutrition can strengthen the
functionality of respiratory muscles.
13. Encourage small frequent meals.
This prevents crowding of the diaphragm.
14. Help the client with ADLs, as necessary.
This conserves energy and avoids overexertion and fatigue.
15. Avail a fan in the room.
Moving air can decrease feelings of air hunger.
16. Encourage social interactions with others that have medical diagnoses of ineffective
breathing pattern.
Talking to others with similar conditions can help to ease anxiety and increase coping skills.
17. Educate client or significant other on proper breathing, coughing, and splinting methods.
These allow sufficient mobilization of secretions.
18. Educate client about medications: indications, dosage, frequency, and possible side
effects. Incorporate review of the metered-dose inhaler and nebulizer treatments, as needed.
This information promotes safe and effective medication administration.
19. Teach the client about pursed-lip breathing, abdominal breathing, performing relaxation
techniques, performing relaxation techniques, taking prescribed medications (ensuring the
accuracy of dose and frequency and monitoring adverse effects), scheduling activities to
avoid fatigue, and provide for rest periods.
These measures allow the client to participate in maintaining health status and improve ventilation.
20. Refer the client for evaluation of exercise potential and development of individualized
exercise program.
Exercise promotes conditioning of respiratory muscles and the client's sense
of well-being
 
Nursing diagnosis : impaired gas exchange related to pneumonia as evidenced by monitoring spo2
82%
Outcome : Client maintains optimal gas exchange as evidenced by usual mental
status, unlabored respirations at 12-20 per minute, oximetry results within normal
range, blood gases within normal range, and baseline HR for client.

 Client maintains clear lung fields and remains free of signs of respiratory distress.
 Client verbalizes understanding of oxygen and other therapeutic interventions.
 Client participates in procedures to optimize oxygenation and in management regimen within
level of capability/condition.
 Client manifests resolution or absence of symptoms of respiratory distress.
1. Client is able to breath and dyspnoea is reduced upto some extent by giving high
fowlers position client and performed suction and nebulization done with duolin and
budecort 

Qans3. The critical question for nurses

What is Nursing Peer Review (NPR)? [Tex. Occ. Code §303.001(5)]

Is an employer required to have a nursing peer review committee? [Tex. Occ. Code §303.0015; Tex. Admin.
Code §§217.19(c) and 217.20(c)]

What part of the nursing peer review process is confidential? [Tex. Occ. Code §§303.006-.007; 303.0075; Tex.
Admin. Code §§217.19(h) and 217.20(j)(3)]

To whom may a nursing peer review committee disclose privileged information (Tex. Occ. Code §303.007)?

DISCUSSION :

Substance use disorder (SUD) is a challenging and complex issue for the nursing profession. Supportive and
educated supervisors and colleagues help to identify nurses with this disease, so they can receive the help they
need promptly. Concerned and preoccupied with your own responsibilities and duties, you may not always
recognize the warning signs of an SUD in a nurse co-worker or colleague. You may misread cues and look for
other explanations for behaviors. That’s why many nurses with SUD are unidentified, unreported, untreated
and may continue to practice where their impairment may endanger the lives of their patients. It can be hard
to differentiate between the subtle signs of impairment and stress-related behaviors, but there are three
things to watch for: behavior changes, physical signs and drug diversion. Behavioural changes can include:
Changes or shifts in job performance;

Absences from the unit for extended periods;

Frequent trips to the bathroom;

Arriving late or leaving early; and

Making an excessive number of mistakes, including medication errors.

CASE STUDY: Karen is a skilled emergency department (ED) nurse in a hospital that treats a large number of
trauma victims. In her personal life, she is struggling with issues of grief and loneliness and feels like “work is
therapy because I can forget for a while.” One day she accidentally goes home with a discarded opiate. She is
an expert on administering pain medications to others and has witnessed relief in her patients many times
after she administers the drugs. That night she is tired and too wound up to sleep, so she thinks there should
be no harm in self-administering the morphine “just this once” to provide relief and some much needed sleep.
She tells herself she will not do it again.... 5 SUD among health care providers also creates significant legal and
ethical responsibilities for colleages.

A week later, Karen again finds herself with a narcotic in her possession, and she purposely takes it home to
self-inject. Within a short period of time, she is diverting on a regular basis and realizes she will experience
withdrawal unless she injects regularly. Karen finds herself working extra shifts, volunteering to medicate co-
worker’s patients who need pain medications, and isolating from other staff members in order to procure and
use the drugs. Fellow nurses in the ED recognize something is wrong, but knowing how highly charged the
department’s environment is, they assume it’s “just stress.”…

Karen’s supervisor, Ann, notices changes in Karen’s demeanour and behaviour, and decides to more closely
monitor her practice. Ann also looks for medication irregularities or discrepancies, record falsifications and any
patterns of complaints by patients. Following hospital procedure and investigating the situation, Ann questions
Karen about her performance and behaviour. Initially denying that she has a problem, when confronted with
evidence of her impaired practice Karen tearfully discloses her SUD. The hospital recommends treatment,
describing her options and that she may be eligible to return to work once she successfully completes a
treatment program, and agrees to an employee assistance program or an alternative to-discipline program
with random monitoring and aftercare. Karen complies and begins recovery.

Nursing implications
: In most states, a nurse may enter a monodisciplinary alternative-to-discipline program, which is designed to
refer nurses for evaluation and treatment, monitor the nurse’s compliance with treatment and recovery
recommendations, monitor abstinence from drug or alcohol use, and monitor their practice upon return to
work. When a colleague who You need to acknowledge that health care professionals are not immune to
developing an SUD… 10 has been treated for an SUD eventually returns to work, it is important that you help
to create a supportive environment that encourages continued recovery. Nurses that educate themselves
about the behaviour changes, physical signs and signals of drug diversion will help not only their colleagues
with SUD, but also protect patients.