Teaching Points for Lark Chesterfield’s Hospitalization

QUESTION

Lark Chesterfield, a 66-year-old woman, presents to the urgent care office complaining of shortness of breath and coughing up “yellow mucus” for the past 24 hours.  She has a history of smoking one pack daily for 48 years and a 12-year history of progressive chronic kidney disease (CKD) based on a decreasing glomerular filtration rate (GFR).

Significant Past Medical History:

Pulmonary:  Community-acquired pneumonia 10 years ago; mild chronic obstructive pulmonary disease (COPD) diagnosed two years ago

Renal:  Mild kidney disease first diagnosed 10 years ago with progressive decreased GFR; Current GFR is 30 mL/min diagnosed two years ago

Immunizations: Prevnar-23 for pneumonia and Influenza vaccines are up to date.

Allergies:  None known

Physical Exam:

Vital signs: temperature 102.2 F (39C), blood pressure 82/48 mmHg, heart rate 128; weight 190 pounds; height 68 inches

The exam reveals a woman who appears older than her stated age. Significant findings include increased work of breathing with decreased breath sounds and rales in the right lower lobe; sinus tachycardia with no murmurs, rubs, or gallops; and 3+ pitting edema.

LABS:

Blood gas indicates a mixed metabolic-respiratory acidosis with pH 7.25; CBC: Hct 30%; MCV 78 fL; WBC 16,800

After the physical exam, blood gas, and chest x-ray, he is diagnosed with right lower lobe pneumonia with sepsis and severe acidosis. She is admitted to the hospital for further evaluation and intensive care where she will receive intravenous antibiotics and further support.

Include ONLY THREE teaching points that directly relate to the issues within the scenario. YOU MUST THINK CRITICALLY ABOUT WHAT IS MOST IMPORTANT FOR THIS HOSPITALIZED PATIENT AT THIS TIME.

TEACHING POINTS
A teaching point is something you say directly to a patient, a parent, or other family member that teaches about the pathophysiology and/or treatment during the clinic or office visit, or the hospital admission that should be remembered after the encounter. (“You will need a follow-up appointment” is an instruction, not a teaching point.)

Do not use jargon – not everyone you talk with will have the same level of education that you do. (Perhaps have a non-medical 13-year-old read your teaching points to see if they can understand what you are saying.) Teaching points do not need references.

If we were discussing the pathophysiology of GOUT, examples of teaching points are:

1. You have a condition called gout. When gout develops, uric acid, the substance that causes gout, can build up, forming sharp, needle-like crystals in your joints or surrounding tissues that cause pain, inflammation, and swelling.
2. Normally, uric acid dissolves in your blood and passes easily through your kidneys into your urine. Accumulation of uric acid can occur when you produce too much uric acid, or your kidneys excrete too little uric acid.
3. You should modify your diet. Gout-causing substances are found in foods such as red meat, organ meats, and liver.  Seafood, including anchovies, sardines, mussels, scallops, trout, and tuna, also produces these substances. Alcoholic beverages, especially beer, and drinks sweetened with fruit sugar promote higher levels of uric acid. You should decrease or avoid these foods to prevent or reduce the frequency of your flair-ups.

Notice the teaching in the above points. Also, notice that ARABIC numbers (1, 2, 3) were used. If an instruction is given, as in example 3, then an explanation (teaching) must be provided about WHY the instruction is important.

NOT

1. I would tell the patient that he needs to modify his diet.

Write what you will say to the patient not what you will do.

2. It is important to keep your next scheduled visit

This is an instruction and teaches the patient nothing about the disease process.

3. If you do not control your gout, damage to your joints may be so severe that amputation is necessary.  This is a bit harsh and a bit extreme. There are softer ways to teach about this.

ANSWER

Teaching Points for Lark Chesterfield’s Hospitalization

Understanding Pneumonia and Sepsis: Mrs. Chesterfield, you have been diagnosed with right lower lobe pneumonia and sepsis. Pneumonia is an infection that causes inflammation and fluid buildup in the air sacs of your lungs, making it difficult for you to breathe. Sepsis is a severe response to infection, and it can cause your body to have an uncontrolled inflammatory reaction, leading to organ dysfunction. It is essential to receive intravenous antibiotics and other supportive treatments in the hospital to help your body fight the infection and stabilize your condition.

Managing Chronic Kidney Disease (CKD): As you have a history of progressive CKD with a GFR of 30 mL/min, it is crucial to take specific measures to protect your kidneys during your hospitalization. Your kidneys play a significant role in maintaining fluid and electrolyte balance in your body. The intravenous fluids and medications used to treat your pneumonia and sepsis can affect your kidney function. Your healthcare team will closely monitor your kidney function and adjust the treatment accordingly to prevent any further kidney damage.

Addressing Acidosis and Fluid Retention: The blood gas results indicate a mixed metabolic-respiratory acidosis, which means there is an imbalance in your body’s pH levels due to the pneumonia and sepsis. Additionally, the presence of 3+ pitting edema suggests fluid retention, possibly related to your decreased kidney function. It is crucial to manage these conditions promptly to restore your body’s acid-base balance and improve breathing and circulation. Your healthcare team will administer appropriate medications and interventions to address these issues and improve your overall condition.

Conclusion

During this hospitalization, Mrs. Chesterfield’s medical team will focus on treating her pneumonia and sepsis, while also closely monitoring her chronic kidney disease and managing any complications that may arise. Understanding the importance of intravenous antibiotics, kidney function monitoring, and acidosis management is vital to ensuring her recovery and overall well-being. Effective patient education will empower Mrs. Chesterfield to actively participate in her care and adhere to the prescribed treatments, leading to improved health outcomes.