Question

A 68 years old male patient was admitted to the medical ward with acute community-acquired pneumonia. His medical history shows that he was diagnosed with paraseptal emphysema 3 years ago. The patient was a smoker for 53 years and consumes 1 pack of cigarettes per day. He stopped smoking three years ago. The patient has a history of hypertension, and diabetes controlled with oral diabetic agents. The patient is confused about place and time. The family stated that this is a new change for the patient. The vital signs during the admission are: BP = 90/50 mm Hg, HR = 101 bpm, RR = 28 breaths/min, and temperature = 38.5 degrees Celcius. The pulse oximeter reading on room air is 85%. The complete blood count is as follows: White Blood Cells = 12,500, platelets = 350,000; hematocrit = 30%; and hemoglobin = 10 g/dL. The arterial blood gas analysis results are: pH, 7.30; PaO2, 55; PaCO2, 50; and HCO3, 25. Chest x-ray results show right lower lobe consolidation, presence of apical bullae, a flattened diaphragm, and a small pleural effusion in the right lower lobe. Lung auscultation indicates severely diminished breath sounds in the right lower lobe and absence of breath sounds at the base. The breath sounds in the rest of the lungs are slightly decreased. The patient complains of fatigue and shortness of breath and cannot finish a short sentence before the respiratory rate increases above the baseline and his nail beds and lips turn a bluish tinge and the pulse oximetry decreases to 82%. The patient is diaphoretic and is using accessory muscles. The patient coughs weakly, but he does not raise any sputum.

a. What nursing assessment findings support the diagnosis of pneumonia?

b. What diagnostic findings support the diagnosis of pneumonia?

c. What nursing diagnoses should the nurse formulate for the patient?

d. What goals should the nurse develop for the patient?

e. What overall interventions should the nurse provide?

Answer 1

a. age, history of emphysema, history of smoking, comorbidity such as diabetes, altered sensorium,hypotension, tachycardai, tachypnoea, redcued oxygen saturation, fever,elevated wbc in blood.elevated haematocrit.aleterd abg, reduced breath sounds and chest movemnets, paradoxical nreathing, use of accessory muscles, laboured breathing,cyanosis ,weak cough, chest xray findings.fatiguegability. thses findings support pnuemonia.

b.

While the physical exam can raise suspicion for pneumonia, the diagnosis can be strengthened using a variety of tests.

Complete Blood Count

A complete blood count is a simple and inexpensive test. A white blood count is one of the blood counts measured. If it is elevated, infection or inflammation is present. It does not specifically let you know if you have pneumonia.

Procalcitonin.

Procalcitonin is a precursor of calcitonin, a protein that is released by cells in response to toxins. It is measured via a blood test. Interestingly, the levels increase in response to bacterial infections but decrease in viral ones.Results are usually positive within 4 hours of bacterial infection and peak within 12 to 48 hours.

Sputum Culture and Gram Stain

Once collected, a Gram stain is applied to part of the specimen and examined under a microscope. A good-quality sputum sample will show several white blood cells but few epithelial cells. Bacteria will appear red or violet and, based on their appearance, can be categorized as one of two classes of bacteria. Narrowing the diagnosis makes it easier to choose an appropriate antibiotic.To find out what specific bacteria is causing your illness, your sample will be cultured in Petri dishes. Once the bacteria or fungi grow, it is tested against different antibiotics to see what treatments will be most effective.

Urine Antigen Tests

Bacterial pneumonia caused by S. pneumoniae and Legionella species has a high incidence of complications. Antigens from these bacteria are excreted in the urine. A simple urine test is available to look for these antigens.

serology-

There are serologic blood tests that may be able to determine when and if you have been infected.4 Serology measures antibodies formed against a specific pathogen. IgM antibodies indicate a new infection whereas IgG antibodies usually show that you have been infected in the past. It can sometimes be difficult to know when IgM antibodies transitioned to IgG antibodies.

PCR and Enzyme Immunoassays

PCR is a test that screens for the presence of specific viral or bacterial DNA in a sample. It is an alternative to serology to screen for atypical bacteria. While results are often available in 1 to 6 hours, PCR cannot be performed on site. It must be processed by a laboratory.

Enzyme immunoassays, however, can be performed as a point of care test with results available in 15 minutes to an hour. These immunoassays use antibodies to detect the presence of specific viral antigens and can screen for multiple viruses at one time.

Chest X-Ray

A chest X-ray may show an infiltrate, which is a collection of pus, blood, or protein in the lung tissue. It can also reveal other signs of lung disease like cavitations and pulmonary nodules.

CT Scan

Bronchoscopy

Bronchoscopy visualizes big airways (trachea or windpipe and large bronchi)—not lungs. Your doctor may decide to take some fluid from your airway for culture if your phlegm culture is negative and you are immunosupressed or if you have a chronic illness requiring precise diagnosis of the cause of your pneumonia. Bronchoscopy is almost never done in an otherwise healthy adult with community acquired pneumonia.

c.Nursing Diagnosis-

1. Ineffective Airway Clearance
2. Impaired Gas Exchange
3. Ineffective Breathing Pattern
4. Risk for Infection
5. Acute Pain
6. Activity Intolerance
7. Hyperthermia
8. Risk for Deficient Fluid Volume
9. Risk for Imbalanced Nutrition: Less Than Body Requirements
10. Deficient Knowledge
11. Deficient Fluid Volume

d.goals-

Planning is essential to establish the interventions that are appropriate for the patient’s condition.

• Improve airway patency.
• Rest to conserve energy.
• Maintenance of proper fluid volume.
• Maintenance of adequate nutrition.
• Understanding of treatment protocol and preventive measures.
• Absence of complications.

• Nursing Priorities

• Maintain/improve respiratory function.
• Prevent complications.
• Support recuperative process.
• Provide information about disease process, prognosis, and treatment.

e. interventions-

These nursing interventions, if implemented appropriately, would result in the achievement of the goals of the management of pneumonia.

To improve airway patency:

• Removal of secretions. Secretions should be removed because retained secretions interfere with gas exchange and may slow recovery.
• Adequate hydration of 2 to 3 liters per day thins and loosens pulmonary secretions.
• Humidification may loosen secretions and improve ventilation.
• Coughing exercises. An effective, directed cough can also improve airway patency.
• Chest physiotherapy. Chest physiotherapy is important because it loosens and mobilizes secretions.

To promote rest and conserve energy:

• Encourage avoidance of overexertion and possible exacerbation of symptoms.
• Semi-Fowler’s position. The patient should assume a comfortable position to promote rest and breathing and should change positions frequently to enhance secretion clearance and pulmonary ventilation and perfusion.

To promote fluid intake:

• Fluid intake. Increase in fluid intake to at least 2L per day to replace insensible fluid losses.

To maintain nutrition:

• Fluids with electrolytes. This may help provide fluid, calories, and electrolytes.
• Nutrition-enriched beverages. Nutritionally enhanced drinks and shakes can also help restore proper nutrition.

To promote patient’s knowledge:

• Instruct patient and family about the cause of pneumonia, management of symptoms, signs, and symptoms, and the need for follow-up.
• Instruct patient about the factors that may have contributed to the development of the disease.