Pneumonia Case History and Initial Assessment

History Taking and Initial Care 👀 Pyelonephritis – Check for fever and urination pain and monitor body temperature rise 👀 FEMORAL FRACTURE – Check accident progress and pain area, check blood pressure and pain score 👀 Pulmonic embolism – Check for shortness of breath and oxygen saturation 👀 Pneumonia – Cough, phlegm color change, body temperature, respiratory rate check 👀 Congestion heart failure (CHF) – Check swelling and shortness of breath, monitor weight change 👀 Myocardial infarction (MI) – Check the location and duration of chest pain, check blood pressure and heart rate 👀 Stroke – Check the time and speech impairment of symptoms, observe blood pressure 👀 Diabetic ketoacidosis (DKA) – Check thirst and frequency of urination, check respiratory rate (Kussmaul breathing) 👀 Sepsis – Check fever, history of infection, monitor changes in body temperature and heart rate

 

 

 

 

Comprehensive Simulation Scenario for Nurse Training: Pneumonia Case History and Initial Assessment

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Scenario Title: Structured Interview, Vital Signs Monitoring, and Diagnostic Preparation for Suspected Pneumonia

Setting: Outpatient Clinic / Emergency Room

Characters:

• Nurse (RN) – Responsible for initial patient assessment and test preparation
• Ms. Hana Kim (Patient) – 54-year-old female presenting with respiratory symptoms

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Phase 1: Patient Identification and Introduction

Nurse: Good morning, Ms. Kim. I’m the nurse assigned to assist you today. To begin, could you please confirm your full name and date of birth?

 

Patient: Good morning. My name is Hana Kim, and my date of birth is March 5, 1970.

 

Nurse: Thank you. I’m going to ask you a few questions to better understand your condition. Everything we discuss will remain confidential. Please let me know if you feel uncomfortable or need a break at any time.

 

 

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Phase 2: History of Present Illness (HPI)

Nurse: When did your cough begin?

 

Patient: It started about five days ago.

 

Nurse: Is your cough dry, or do you cough up any phlegm?

 

Patient: I’m producing a lot of phlegm.

 

Nurse: What color is the phlegm? Is it clear, yellowish, green, or blood-tinged?

 

Patient: It’s mostly yellowish.

 

Nurse: Is the cough present throughout the day or worse at certain times?

 

Patient: It’s worse in the early morning and at night.

 

Nurse: Have you experienced a fever, chills, or body aches?

 

Patient: Yes, I’ve had a fever and chills. I also feel very tired.

 

Nurse: Do any specific activities or environments worsen your breathing or cough?

 

Patient: Cold air and lying down make it worse. Sitting up seems to help.

 

Nurse: Do you experience any chest pain or shortness of breath?

 

Patient: Yes, I feel short of breath, especially when climbing stairs.

 

Nurse: On a scale of 0 to 10, with 10 being the most severe, how would you rate your cough, shortness of breath, and fatigue?

 

Patient: My cough is around 7, shortness of breath is 6, and fatigue is 8.

 

 

 

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Phase 3: Past Medical History (PMH)

Nurse: Have you ever had pneumonia or bronchitis before?

 

Patient: Yes, I had pneumonia two years ago.

 

Nurse: Do you have any chronic respiratory conditions, such as asthma or chronic obstructive pulmonary disease (COPD)?

 

Patient: No, I don’t have any chronic lung issues.

 

Nurse: Have you been vaccinated for pneumonia or influenza in the past year?

 

Patient: I got a flu shot last winter but didn’t get the pneumonia vaccine.

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Phase 4: Family History (FH)

 

Nurse: Is there any family history of respiratory diseases, such as asthma, tuberculosis, or lung cancer?

 

Patient: My father had asthma, but no one else has had lung issues.

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Phase 5: Social History (SH)

Nurse: Do you currently smoke, or have you smoked in the past?

 

Patient: I smoked for about 15 years but quit 10 years ago.

 

Nurse: Are you exposed to any dust, fumes, or chemicals at work or home?

 

Patient: No, I work in an office setting with good ventilation.

 

Nurse: Do you live with anyone who smokes?

 

Patient: No, my husband quit smoking a few years ago too.

 

Nurse: Do you engage in regular physical activity?

 

Patient: I walk a few times a week but haven’t exercised lately because of my symptoms.

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Phase 6: Medication History and Allergies

Nurse: Are you currently taking any medications, vitamins, or supplements?

 

Patient: Just some over-the-counter cold medicine—cough syrup and paracetamol.

 

Nurse: Have you used antibiotics recently?

 

Patient: I haven’t taken antibiotics in over a year.

 

Nurse: Do you have any known allergies to medications, food, or environmental triggers?

 

Patient: No, I’m not allergic to anything that I know of.

 

 

 

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Phase 7: Vital Signs Assessment

Nurse: I’ll now check your vital signs: temperature, blood pressure, pulse, and respiratory rate. Please let me know if you feel uncomfortable.

 

 

7.1 Temperature Measurement

Nurse: I’ll start with your temperature using a tympanic (ear) thermometer. Have you had any recent ear infections?

 

Patient: No, I haven’t.

(Nurse performs hand hygiene, places probe cover, gently pulls the ear upward, inserts thermometer.)

 

Nurse: Your temperature is 38.4°C, which confirms that you have a fever.

 

 

7.2 Blood Pressure Measurement

 

Nurse: Next, I’ll measure your blood pressure. Any history of surgeries or medical devices in your arms?

 

Patient: No, nothing like that.

(Patient’s arm is rested at heart level. Nurse wraps cuff, inflates, auscultates using stethoscope.)

 

Nurse: Your blood pressure is 145/90 mmHg. That’s slightly elevated, which can happen due to fever and discomfort.

 

 

7.3 Pulse Rate Measurement

 

Nurse: I’ll now check your pulse. Please relax your wrist.

(Nurse locates radial artery, counts for 60 seconds.)

 

Nurse: Your pulse is 110 beats per minute, which is elevated—likely related to your fever and respiratory distress.

 

 

7.4 Respiratory Rate Measurement

 

Nurse: Lastly, I’ll assess your respiratory rate. Please continue breathing normally while I observe.

(Counts chest movements discreetly for one minute.)

 

Nurse: Your respiratory rate is 24 breaths per minute—above the normal range, which corresponds with your shortness of breath.

 

 

 

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Phase 8: Summary of Assessment and Clinical Impression

 

Nurse: Ms. Kim, based on your symptoms and the vital signs we’ve collected:

• Fever (38.4°C)
• Elevated blood pressure (145/90 mmHg)
• Increased heart rate (110 bpm)
• Tachypnea (24 breaths/min)

These findings are consistent with a lower respiratory tract infection—most likely pneumonia. Your cough, phlegm production, fatigue, and fever align with a classic presentation.

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Phase 9: Diagnostic Procedures and Preparation

 

Nurse: We’ll now proceed with the following diagnostic tests:

1. Chest X-ray: To identify areas of lung infection or fluid.
2. Blood tests: To assess white blood cell count and markers of inflammation.
3. Sputum collection: To identify the causative organism—bacterial or viral.

Nurse: For the sputum sample, please try to produce a deep, thick sample from your lungs, not just saliva. If you’re having trouble, we can provide instructions or use a humidifier.

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Phase 10: Patient Education and Home Instructions

 

Nurse: It’s important to:

• Stay hydrated by drinking plenty of fluids.
• Get adequate rest and avoid physical exertion.
• Monitor your symptoms for worsening cough, higher fever, or difficulty breathing.
• Avoid smoking and exposure to cold air.
• Take all prescribed medications exactly as directed.

If symptoms get worse or you experience chest pain, confusion, or shortness of breath at rest, contact us immediately or visit the emergency department.

Patient: Thank you for explaining everything so clearly.

Nurse: You’re very welcome, Ms. Kim. Let’s proceed with the tests now. Let me know if you need anything or feel unwell during the procedures.

 

 

 

 

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Learning Objectives for Nurse Trainees

• Apply structured case history techniques to respiratory infections using MECE principles
• Collect a comprehensive HPI that includes symptom pattern, triggers, and duration
• Assess vital signs with accurate technique and correlate findings with pneumonia symptoms
• Provide patient education about the diagnostic process and symptom monitoring
• Initiate preparation for essential diagnostic tests and promote patient comfort during assessments

End of Scenario

 

 

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Pneumonia Case History and Initial Assessment