The Diagnosis of Right-Sided Pneumonia Leading to Acute Respiratory Failure - Case Study Example

1. Explain with rationale, relevant assessment data which supports the diagnosis of right sided pneumonia leading to acute respiratory failure. Postoperative pneumonia (Brooks, A., 2001) is clinical signs of infection occurring 48 hours after surgical operation of the abdominal or chest injury due to pseudomonas aeruginosa that is very common in the intensive care setting. Mr. Ivmiesvich suffers from hospital acquired pneumonia following post operation (Atkinson, 2008). His immune system is partly impaired by surgery’s triple therapy of azathioprine, corticosteroids and cyclosporine that has immunosuppressive effect and opened his body to infections. Other factors that predisposed him to post operative pneumonia are his age (Moore, T. (2007).)-73 years; debilitated and bedridden and was unconscious from anesthesia. He was therefore exposed to the risks of aspiration pneumonia as well as chemical pneumonitis. Aspiration pneumonia results when tiny particles from mouth dribble and are inhaled/aspired into the airways (Lee, G. & Bishop, P., 2002) but due to impaired immune system caused by imunosuppression, they are not cleared and cause aspiration pneumonia. The clinical signs of aspiration pneumonia are chest pain, due to friction arising from decreased pleural fluid, fever (temperature 38oC, normal 36.9oC), increased respiratory rate (28 breaths/minute accompanied by shortness of breath. Chemical pneumonitis is a special form of aspiration pneumonia and occurs when a person inhales materials that are toxic to the lungs. The commonly inhaled toxic substance is stomach acid and symptoms are similar to aspiration pneumonia. Mr. Ivmiesvich developed increased respiration -108 beats/min (normal 90 bpm) and became tachycardiac (Heart Rate >102 beats per minute) (marieb, 2004) triggering metabolic rate and consequently leading to increase in heat. He underwent changes in respiratory parameters like purulent secretions and worsening hypoxemia that affected alveolar hypoventilation. A further diagnosis was done by listening to the chest with stethoscope (Nursing Times, 2008) and distinctive crackling sounds heard. These crackling sounds were caused by narrowed airways or filling of the normally air-filled alveolus, showing consolidation had occurred. There was therefore a high blood (Peters, J., & Chalaby, A., 2004) pressure) of 165/98 mmHg (normal is 120/80 mmHg ) for systolic and diastolic respectively implying organs like brain were being deprived oxygen. Mr. Ivmiesvich has diminished oxygen content in his blood, the partial pressure of oxygen was 58 mmHg (normal range 80-100mm Hg) and Partial pressure of carbon dioxide of 54 mmHg (normal range is 35-45 mmHg) and SaO2 of 89% (the normal range is 95%-100%) don’t favour uptake of oxygen (Pruitt and Jacobs, 2004). The demand of oxygen is increased and an oxygen debt is likely to occur. This forces a compensation heart to increase rate and depths of respiration increase in order to increase Partial pressure of oxygen (Woodrow, P., 2004) and decrease Partial pressure of carbon dioxide. The accumulations of carbon dioxide lead into increase of acidosis –PH 7.3. (Normal range is 7.35 to 7.45) thus indicating presence of respiratory acidosis (Pruitt and Jacobs, 2004; Woodrow, 2004). It was confirmed with X-ray. The infected tissue appeared on the X-ray as dense white patches. X-ray was taken to confirm signs of leucocytosis but the results cannot be relied on since it can result from atelectasis, pulmonary embolism or pulmonary edema that MR. Ivmiesvich doesn’t have. 2. Discuss three (3) priority interventions to implement over the next six hours to manage the problems identified from the assessment data. Mr. Ivmiesvich requires extensive assistance and is totally dependent. His pneumonia risk indices are: heart rate of 108 beats per minute put him at score 1, partial pressure of oxygen is 58mmHg putting him at score 2, a male at score 1. His overall score (1-4) give him a low mortality of approximately 2-3%. It is evident that Mr. Ivmiesvich is not responding to oxygen administered at 6L/min (Woodrow 2007) via the Hudson mask as evidenced by (Beattie, 2006) pulse oximetry measurement of 89% and partial pressure of oxygen of 89%. He therefore cannot respond to higher oxygen concentrations delivered via a venture mask implying hypoxemia is secondary to intrapulmonary shunt (Carter, R., Williams, J., McComb, J., Sawyer, R. & Tiep, B.,2005). Consequently, endotracheal intubation has breached airway defenses, has impaired cough and mucocilliary clearance and opened gates for microaspiration of bacteria –laden secretions that pool above the inflated endotracheal tube cuff. In addition, the bacteria have formed a film on and within endotracheal tube that protects them from antibiotics and host defenses. The immediate intervention would therefore be clearing of secretions. He should be given intravenous antibiotic for start. The antibiotic should be started before the bacterium is indentified by analyzing which bacterium is likely to have caused aspiration pneumonia. The most common important bacterium is pseudomonas aeruginosa, which is very common in pneumonia acquired in intensive care setting and in patients with cystic fibrosis, bronchiectasis or neutropenia. He should receive first generation cephalosporins or erythromycin (Galbraith, A. & Bullock, S. & Manias, E., 2004) that has a higher sensitivity test and that the bacterium is less likely to develop resistance (Atkinson, 2008). Measurements of the inflammatory mediators in broncho-alveolar lavage fluid should be performed. For instance, a concentration of soluble triggering receptor expressed as myeloid cells- a protein expressed and shed by the immune system cells during infections->5pg/ml will help to identify the particular bacterium that caused it and also a blood and pleural fluid culture should be able to facilitate identification of the pneumonia and the bacterium responsible. The other interventions that should follow clearance of secretions are rehabilitation of the lung and airway, alleviation of the acute respiratory distresss syndrome and bronchoscopy. Clearing secretions The trachea should be suctioned to clear secretions and aspirated food particles out of the airways. This will help to increase Bohr Effect and alleviate partial pressure (Pruitt, W., & Jacobs, M., 2004) of carbon dioxide, (decrease it from 54 mmHg to around 35-45 mmHg) and partial pressure of oxygen (be increased from 58 mmHg to around 80-100 mmHg) and eventually lower PH (Smythe, 2005) to normal (7.35-7.45). The three factors, partial pressure of carbon dioxide, Partial pressure of oxygen and PH had made him to progress to type II hypercapnoeic (Peters, J., & Chalaby, A., 2004) or hypoxemic acute respiratory failure (ARF) that is conventionally termed as ventilation failure (Smyth, M. (2005). ,Moore, 2007). Following suction MR. Ivmiesvich will be in a position to respond well to (Pierce, L. , 2007) Non-Invasive Positive Pressure Ventilation (NIPPV) because atelectasis had occurred (CXR-right sided basal consolidation and collapse) that is responsible for intercostals muscle recession and deep labored breathing, as well as affecting the pleural membranes that had decreased secretion of pleural fluid leading into friction that triggered the pains (Preston, R., 2001) . NIPPV will help in re-inflation and improve oxygenation (Woodrow, 2003). Otherwise, non invasive ventilation can be done using positive airway pressure (PAP) or bi-level positive airway pressure (BiPAP) (British thoracic society, 2002). BiPAP (Meacher, S., 2005) helps to prevent the breach in the airway defense that occurred with endotracheal intubation for acute respiratory failure with acidosis, (PH 7.3) by virtue of his pneumonia risk index score, Mr. Ivmiesvich needs to be closely monitored because noninvasive ventilation techniques are not always successful. Hemodynamic instability, deteriorating mental status, and an increasing respiratory rate indicate their failure. Increasing respiratory acidosis, the inability to maintain adequate oxygen saturation, and problems with respiratory secretions can limit the success of this technique. Oxygen therapy works towards alleviation of acute respiratory distress syndrome (Kelly, C., & Riches, A., 2007). The intervention care for Mr Ivaniesvich should then enter oxygen therapy (McGloin, S., 2008) which helps to correct hypoxemia thus preventing hypoxia (Beattie, S., 2006). However the cause of the hypoxemia should be sought before selecting oxygen delivery system (Kelly, C., & Riches, A. (2007). For example oxygen administered at 6L/minute via a simple face mask should improve the partial pressure oxygen (PaO2) and oxygen saturations (SaO2) unless hypoxemia is secondary to V/Q mismatch. Mr Ivaniesvich is receiving oxygen at the rate of 6L/minute via a hudson mask which is ineffective (Bennett, C., 2003) as evidenced by his pulse oximetry measurements of 89% (it decreased from expected 95% to 100% and PaO2 reading of 58 mmHg that are far below the baseline values of 80-100 mmHg. Alternatively a venturi mask has a higher oxygen delivery should be used. Care should be taken not to predispose MR. Ivaniesvich to oxygen poisoning (Woodrow, P., 2007). There is a challenge though with the use of a venture mask, in that (Beattie, 2006) hypoxemia secondary to intrapulmonary shunt is usually not responsive to high concentrations of oxygen and Mr. Ivaniesvich will require positive pressure ventilation (Beattie, S., 2007). Semi upright or upright positioning of Mr. Ivaniesvich will help to reduce the risk of aspiration as compared with recumbent positioning. This is limited by virtue of his abdominal hip surgery. Intervention should be tailor made to ensure the comfort of the patient (Woodrow, 2003). Normally, patients of acute respiratory failure are anxious and respond well to a therapeutic touch (preston 2001; ahern and Philpot 2002; Moore, 2007). Mr. Ivmiesvich should be helped to develop a cough, by being encouraged to move hands as if to hug a friend. The pillow should not be used because it might have been the source of the aspirated particles. This should be followed by selective decontamination of the oropharynx by using effective antibiotics governed by sensitivity and should start by using Clindamycin and if a solid particle had been inhaled , it can be removed by using bronchoscopy. Then MR. Ivmiesvich should undergo physiotheraphy, postural drainage and assisted coughing (copstead and Banasik, 2005). Mr. Ivmiesvich should then be encouraged to make movements out of the bed and into a chair. The mechanical movement would trigger a reflex action ( Pruitt and Jacobs, 2005) that will make him to cough and help remove any other secretions (Pruitt and Jacobs). Mr. Ivmiesvich should then take deep breathing exercises to help clear secretions. This will also have an effect of improving diffusion gradient. If possible, sitting in a high fowler’s position (Pruitt, W., & Jacobs, M. 2005) could enable possible deeper breaths and generation of powerful coughs. This cannot be adopted due to his abdominal hip surgery. Medication: Mr. Ivmiesvich can be given mucolytic agents such as acetyl cysteine that can be administered through a nebulizer to decrease viscosity of the mucus and help in the removal of the mucus by ciliary action (Galbraith, Bullock and Manias, 2004). Morphine can be used for the pain management but its use is restricted (Mcenroe-ayers and lappin 2004) it has other medical side effects than just pain management. Opiods should not be used because they can suppress respiratory drive and bring in a problem of acute respiratory failure. Pain management drugs should not have any respiration suppression. Reference List Ahern, J., & Philpot, P (2002). Assessing acutely ill patients on general wards. Nursing Standard 16 (47) 47-54. Atkinson, M. (2008). Evidence-Based Nursing Monographs, Pneumonia. Mosby’s Nursing Consult [Electronic Version] Retrieved 14 March, 2008 from: http://www.nursingconsult.com.ezp01.library.qut.edu.au/das/news/body/2/ebnm/0/19 Beattie, S. (2006). Back to basics with O2 therapy. RN 69 (9) 37-40. Beattie, S., (2007). Bedside Emergency – Respiratory Distress. RN, 70 (7) 35-39. Bennett, C (2003). Nursing the Breathless Patient. Nursing Standard, 17(17) 45-51. Brown, D., & Edwards, H. (2005). Lewis’s medical-surgical nursing. Elsevier Mosby, St. Louis. Brooks, A. (2001). Postoperative Nosocomial Pneumonia: Nurse –Sensitive Interventions. AACN Clinical Issues 12,(2) 305-323. Carter, R., Williams, J., McComb, J., Sawyer, R. & Tiep, B. (2005). Evaluating Patients with Respiratory or Acid-based Disorders. RT Magazine Retrieved 4 April, 2008 from: http://www.rtmagazine.com/issues/articles/2006 Copstead, L., & Banasik, J. (2005). Pathophysiology (3rd ed.) Elsevier Saunders, St. Louis. Galbraith, A. & Bullock, S. & Manias, E. (2004) Fundamentals of Pharmacology (4th ed.) Prentice Hall: Australia. Hill, N., Brennan, J. Garpestead, E., & Nava, S. (2007) Noninvasive Ventilation in Acute Respiratory Failure. Critical Care Medicine, 35 (10) 2402-2407. Retrieved 7/05/08 from: http://www.medscape.com/viewarticle/565661 Kelly, C., & Riches, A. (2007). Best Practice: Emergency oxygen for respiratory patients. [Electronic version] Retrieved 20 April, 2008 from: http://www.nursingtimes.net/supplements/Respiratory_supplement/2008/01/best_prac Lee, G. & Bishop, P. (2002). Microbiology and infection control for health professionals (2nd ed.). Prentice Hall: Australia. Marieb, E. (2003). Essentials of Human Anatomy & Physiology (7th edn.) Benjamin Cummings, San Francisco. McGloin, S (2008). Administration of oxygen therapy. Nursing Standard, 22(21) 46-48. Meacher, S. (2005). The use of Bi-level positive pressure ventilation in the treatment of acute respiratory failure within the emergency department. Australasian Emergency Nursing Journal 8 21-26. Moore, T. (2007). Respiratory Assessment in Adults. Nursing Standard, 21 (49), 48-56. Nursing Times (2008). Pneumonia 2: Effective nursing assessment and management. Retrieved 23 April, 2008 from: http://nursingtimes.net Nursing Times.net (2007). Non-invasive positive pressure ventilation. Retrieved 24 April, 2008 from: http://www.nursingtimes.net/ntclinical/noninvasive_positive_pressure_ventilation.html Peters, J., & Chalaby, A. (2004). Acute Respiratory failure, part 1: Establishing the diagnosis. The Journal of Respiratory Diseases 25 (7), 294- 297. Peters, J., & Chalaby, A. (2004). Acute Respiratory failure, part 2: Differential diagnosis and management. The Journal of Respiratory Diseases 25 (8), 330-336. Pierce, L. (2007). Noninvasive Positive-Pressure Ventilation pp. 255-263. Management of the mechanically ventilated patient, Saunders, St Louis Missouri. Preston, R., (2001) Introducing non-invasive positive pressure ventilation. Nursing Standard 15 (26), 42-45. Pruitt, W., & Jacobs, M. (2005). Clearing away pulmonary secretions. Nursing 2005, 33 (7) 37-41. Pruitt, W., & Jacobs, M. (2004). Interpreting Arterial Blood Gases: Easy as ABC. Nursing 2004, 34 (8) 50-53. Smith, T. (2004). Oxygen therapy for older people. Nursing Older People, 16 (5) 22-28. Smyth, M. (2005). Acute Respiratory Failure: Part 1. Failure in Oxygenation: When a patient loses the ability to oxygenate the blood. American Journal of Nursing, 105 (5) Smyth, M. (2005). Acute Respiratory Failure: Part 2. Failure in Ventilation. American Journal of Nursing. Wagner, K., Johnson, K., & Kidd, P. (2006). High Acuity Nursing, (4th ed.) Pearson Prentice Hall: New Jersey. Woodrow, P (2003). Using non-invasive ventilation in acute wards: part 1 Nursing Standard18 (1) 39-44. Woodrow, P (2003). Using non-invasive ventilation in acute wards: part 2 Nursing Standard18 (1) 41-44. Woodrow, P (2004). Arterial Blood Gas Analysis. Nursing Standard 18 (21) 45-52. Woodrow, P (2007). Caring for patients receiving oxygen therapy. Nursing Older People, 19(1). Read More