Priorities on Patients Care Pneumonia - Case Study Example

A discussion about the patient presented in your viva voce Introduction Mr. X is a 48 year old female who was admitted at the pulmonary ward after a period of increasingly productive cough that was not resolving despite 2 course of ABx doxycycline. Other presenting symptoms included green sputum, reduced exercise tolerance, sweaty, chest pain with cough, and fluctuating appetite. The patient is classified as a high risk patient due to previous medical history and there is clinical and radiological evidence of LLL pneumonia. The patient has been classified as high-risk patient because she has a chronic disease, namely morbid obesity, asthma and severe OSA. High risk groups are at high risk of acquiring pneumonia (Zafar, 2016, p. 3). The patient lives alone but gets domestic assistance at home. She has been independent but uses walking stick or frame for mobility. The patient routinely takes aspirin, Lipitor, coloxyl, esomeprazole, aripiprazole, coloxyl, propranolol, pregabalin, paracetamol, vit D and Calcium, among other medications. She smokes 40 sticks daily. The patient has a history of morbid obesity, iron deficiency, multiple lacuar infarct, depression, asthma and severe OSA. On examination, the patient was afebrile, desaturations to 85 with exercise, and the patient appeared older than his age. This paper will focus on the pathophysiological/ pharmacological changes of the patient’s condition as well as the assessment and diagnostic activities/tests performed on the patient. Further, the paper will present recommendations on patient’s care priorities and finally present a reflection PEP feedback. Pathophysiological/ pharmacological changes The patient was diagnosed with LLL pneumonia as evidenced by the clinical and radiological evidence. Pneumonia is an acute respiratory disease linked to radiological pulmonary shadowing which can be either segmental, lobar or mutilobar (Akter, 2015, p.1). The patient in this case study has multilobar pneumonia. Gómez-Junyent (2014, p.1) defines pneumonia as the presence of an infiltrate on a chest radiograph and an acute disease typified by symptoms such as new cough,  distorted breath sounds on auscultation, chest pain, dyspnea, fever/hypothermia, among other symptoms. In this case study, there are various symptoms that indicate that the patient has pneumonia. The patient has been experiencing productive cough, chest pain, upper airway transmitted sounds, in addition to poor breathing and all these symptoms are associated with pneumonia Gómez-Junyent (2014, p.1). Other symptoms that may indicate presence of acute respiration tract infection include rigors, sweating, fatigue, anorexia, headache, dyspnoea, and change in the colour of respiratory secretions (Akter, 2015, p.1). The patient has been feeling tired, is sweaty, loss of appetite and also there is colour change of cough, which is black. According to Akter et al (2015, p. 2) pneumonia is normally spread through droplet infection. There are intrinsic and extrinsic causes that lead to development of pneumonia. Extrinsic factors consist of exposure to causative agents, pulmonary irritants or pulmonary injury while intrinsic factors are linked to the host. The protective upper airway reflexes may be lost and this allows contents from the upper airways to be aspirated into the lung (Schellack & Schellack, 2015, p. 30). Some causes of loss of protective upper airway reflexes include neurological causes like stroke (Akter et al, 2015, p. 2). Gómez-Junyent (2014, p.2) also explains that bacteria from the upper airways spread and reach the lung parenchyma. After reaching the lung parenchyma, combination of various factors such as the virulence of the microbe, weakened immunity and general health of the patient might result to bacterial pneumonia. This is supported by Menénendez et al (2012, p. 160) who explains that after the microorganism enters within the alveoli, there is an inflammatory response against the microbe. As aforementioned, the patient in this case has weakened local defences due to weak immunity because of the patient’s chronic illnesses. In addition, the overall health status of the patient is poor due to the chronic illnesses the patient has. The weak immune system makes the patient vulnerable to infections due to impaired immune response. Smoking in this patient has also contributed to dysfunction of defense mechanisms because the patient is not exposed to other inhaled toxins other than tobacco smoke (Schellack & Schellack, 2015, p. 30). Numerous factors such as risk factors can weaken the immune system as well as the efficacy of local defences and hence predispose a person to pneumonia. The patient in this case study was predisposed to various risk factors such as chronic illness and smoking. The classical pathological response progresses via the phases of congestion, red and grey hepatisation and eventually resolution with slight scarring or none (Akter et al, 2015, p. 2). According to Menénendez et al (2012, p. 160), during a pulmonary infection as in case of pneumonia, acute inflammation is caused by the movement of neutrophils from the capillaries to the airspaces and this results to formation of a collection neutrophils. The neutrophils phagocytise microorganisms and destroy them with reactive oxygen species and de-gradative enzymes. In addition, the neutrophils extrude a chromatin meshwork that contains antimicrobial proteins that entrap and kill extracellular bacteria. In pneumonia, the lungs fill with pus and as a result the lungs stiffen. Consequently, the breathing of a patient becomes fast with stiff lungs and this is evident in the patient where at times she becomes breathless especially when doing tasking activities and getting fatigued easily. As the pneumonia worsens, the stiffness of the lungs increases and hence the lungs fail to expand appropriately. Severe pneumonia is typified by a lot of pus within the lungs and hence lung stiffness increases (Akter et al, 2015, p. 2). There are various risk factors for pneumonia for this patient. Most of the risk factors are allied to the impairment of the efficacy of the host immune defence and the risk factors are allied to higher mortality risk (Steel et al, 2013, p. 3). The most common risk factors for pneumonia include smoking; underlying comorbid conditions such as diabetes, chronic cardiorespiratory, HIV; lifestyle factors such as taking alcohol and smoking; ageing and medications (Steel et al, 2013, p. 3). In this patient, some of the risk factors include smoking and presence of underlying comorbid conditions such as diabetes and asthma. Evidence indicates that smoking is an important risk factor for many infectious diseases (Steel et al, 2013, p. 3). In pneumonia, the key mechanisms for predisposition are allied to the suppressive effect of smoking on the protective actions of the airway mucociliary clearance mechanism and suppressive effect on the different aspects of the intrinsic and adaptive immune systems of the host. In addition, smoking directly impacts microbial pathogens by promoting their virulence and probably also promotes antibiotic resistance (Steel et al, 2013, p. 3). Investigations Presenting History The patient presented with complains about continuous productive cough, green sputum, reduced exercise tolerance, sweaty, chest pain with cough, and fluctuating appetite, nil headache and nil sore throat (Steel et al, 2013, p. 4). The presenting history was used in making a differential diagnosis. The symptoms were indicative of pneumonia. Evidence shows that pneumonia should be considered when a patient presents with more than two of these symptoms: fever, rigors, coughing, and change in sputum colour, chest pain/discomfort and dyspnoea (Steel et al, 2013, p. 5). As indicated above, the patient presented with more than two of these symptoms and hence pneumonia was considered for the patient. Taking the presenting history was important in informing the diagnosis as well as the care and management of the patient. For example, it was obtained that the patient was coughing, had chest pain and fever and accordingly the appropriate medications and care management was started. Vital signs Assessment of vital signs is an important aspect during patient assessment. This is because vital signs forms the basis of management of a patient’s condition and also this data is helpful in monitoring the improvement, stability or deterioration of a patient. In this case study, the patient’s vital signs were as follows: The patient was afebrile and hameodynamically stable; temperature 37.6; heart rate 75; BP 101/67; SaO2 90%-92% on desaturations to 85% with exercise and not clinically dry. The patient’s oxygen saturations are SaO2 90%-92% on desaturations to 85% with exercise. A range of SaO2 94-99% is normal for healthy adult. This indicates that the patient’s SaO2 are lower than the normal values. This indicates poor blood oxygen content and is an indication of conditions that interfere with gas exchange for instance pneumonia (Steel et al, 2013, p. 5). The patient’s heart rate is 75 and hence it is within the normal range. The normal pulse rate ranges between 60-100 beats per minute. The patient is afebrile and this means the patient did not have elevated temperature. Obtaining the patient’s vital signs was important in identifying the abnormal findings that assisted in providing care for the patient. According to Steel et al (2013, p. 3), when proving nursing care for patients with pneumonia, it is always important to monitor the patient’s vital signs consistently because patient’s with pneumonia may develop sepsis and this drastically increases the mortality rate of such patients. Monitoring of the patient’s vital signs is also important in ensuring that a patient’s deteriorating condition is identified early and also potential complications are prevented (Stein, 2012, p. 1840). Physical examination/general observations The patient appeared older than her age and was dishevelled as well. The patient was also alert and well oriented. In regard to respiration, there is reduced AE throughout reduced expansion. The patient is also obese and the patient has not voided in spite of 3L fluid. There is an indication of 450ml in bladder. Physical examination and general observations were important because the findings provided important clues to the patient’s underlying medical condition. ECG An ECG was performed on the patient to obtain a clear history regarding the onset and development of the chest pain. In addition, the patient has dyspnea as typified by the patient’s shortness in breath. According to Stein (2012, p. 1840) ECG is a diagnostic test for patients with chest pressure, chest pain and dyspnea. Dyspnea is a common symptom in patients with pneumonia and bronchitis as well as myocardial infarction and hence the ECG investigation was necessary to find out if the patient was having a heart failure or pneumonia (Steel et al, 2013, p. 5). The clinical significance of the ECG in pneumonia is also important in the differential diagnosis of pneumonia and pulmonary embolism. Findings on the ECG can indicate presence of pneumonia when interpreted within the appropriate context and result to definitive imaging tests (Stein, 2012, p. 1840). Supporting symptoms that rule out other conditions such as heart failure or pulmonary embolism and suggest the patient may be having pneumonia include the fever, exacerbations, sweating, sputum and respiratory rate higher than 25 breaths per minute. An ECG is used as the reference standard for patients suspected to be having pneumonia and a chest radiograph is the standard against comparison of the clinical examinations for pneumonia (Watkins & Lemonovich, 2011, p. 1301). The ECG was used to inform the plan for the management and care of the patient because an abnormal ECG indicates the probability of a patient having a heart failure as well as brain natriuretic peptide (Watkins & Lemonovich, 2011, p. 1301). Therefore, an ECG helped in establishing whether the patient was at risk of a heart failure. Bloods Blood tests indicated that the patient’s inflammatory markers were high; CRP 100; WCC 12.3; Hb 115. Blood tests were important in confirming the infection the patient had as well as in identifying the kind of organism that was causing the infection. Procalcitonin levels are normally high in patients with bacterial infections such as pneumonia (Watkins & Lemonovich, 2011, p. 1301). For instance, white blood cell count as well as values of C-reactive protein is helpful in pneumonia diagnosis. Increased value of white blood cell count is an indication of a bacterial infection and the pneumonia microorganism can be indentified through blood culture (Watkins & Lemonovich, 2011, p. 1302). Investigation of bloods is important in management and care of the patient because it helps in confirming the exact microorganism and consequently prescribe treatments responsibly and accurately.  Recommendations The patient is fit for discharge as indicated by the improved chest x-ray results, improved saturation and controlled blood sugar. 1. Advice on need to report observed signs and symptoms The patient will be advised to report whenever she notices increased dyspnea, increased body temperature and presence of adventitious sounds Rationale This will help in preventing deterioration of the patient’s condition because medical response will be initiated immediately (Horwitz et al, 2014, pp. 6) 2. Adhere to the treatment regimen The patient will be educated on the importance of complying with medications and not skipping drugs as she has done before. The patient will also be advised to increase fluid intake and perform deep breathing exercise for minimum of two times daily. Rationale The patient is on antibiotic treatment regimen and failure to adhere may result to antibiotic resistance. Failure to adhere to medications may also result to health complications. For instance, if the patient fails to take her diabetes medications it may result to imbalanced glucose levels which is fatal (Horwitz et al, 2014, pp. 6) 3. Inform the patient about follow-up The patient will be informed about her out-patient clinic appointment after one week Rationale This is important to evaluate if the patient is responding to treatment and adhering to the treatment regimen (Horwitz et al, 2014, pp. 6) 4. Ensure the patient has support after discharge The patient will move to the sister’s place after discharge and therefore she will not be living alone anymore Rationale The rationale is to ensure the patient gets enough rest and she has someone to provide care and help with household chores, among other activities (Horwitz et al, 2014, pp. 6) 5. Physiotherapy appointment The patient was booked for a physiotherapy appointment after 10 days Rationale The physiotherapy will examine if the patient’s breathing is functioning well and further advice the patient on the breathing exercise should follow (Horwitz et al, 2014, pp. 6) 6. Patient education The patient will be educated about the dangers and risks associated with smoking. The patient will further be advised on how to go about on smoking cessation Rationale Smoking is an important risk factor for pneumonia and its complications and hence it will be important for the patient to stop smoking (Horwitz et al, 2014, pp. 6) Reflection on PEP feedback The feedback provided by my facilitator indicated my performance regarding my clinical skills during PEP. Generally, my performance was average. I performed extremely well on patient’s presentation especially with the introduction, situation and background aspects. However, my performance was poor regarding the patient’s assessment and recommendations. The feedback indicated that I did not adequately tackle the patient’s assessment and recommendation segments because I provided inadequate information. This feedback was important because I was able to improve on my weak points. For instance, when developing this paper, I ensured that I included adequate information on all sections. I also researched comprehensively and used the most recent evidence to locate enough information in this paper. This feedback is significant to my ongoing professional development because I will implement the feedback and the suggested areas of improvement. Therefore, the feedback has responded to my learning needs. This includes my nursing skills especially the assessment skills. By putting the suggested new skills and knowledge in the feedback into practice, I will be participating in professional development. According to the NMBA (2010, p. 2) an RN contributes to quality healthcare through continuous learning and professional development, research and clinical supervision. An RN is expected to develop his/her professional practice according to the health needs of the society. Therefore, this feedback has contributed to my professional development because it has helped me improve my weak points and also research on the most recent evidence on the topic. In future, I plan to constantly participate in effective professional development in order to endeavour improve my clinical and nursing skills. Reference List Akter S, Shamsuzzaman A & Jahan F, 2015, Community Acquired Pneumonia, Int J Respir Pulm Med, vol. 2, no. 16. Gómez-Junyent J, Garcia-Vidal C, Viasus D, Millat-Martínez P, Simonetti A, Santos MS, et al, 2014, Clinical Features, Etiology and Outcomes of Community-Acquired Pneumonia in Patients with Chronic Obstructive Pulmonary Disease, PLoS ONE, vol. 9, no. 8. doi:10.1371/journal.pone.0105854. Horwitz L, Moriarty J, Chen C, Fogerty R, Brewster U, Kanade S, Ziaeian B, Jeng G & Krumholz H, 2014, Quality of discharge practices and patient understanding at an academic medical center, JAMA Intern Med, vol. 173, no.18, pp: 1-8. Menénendez R, Torres A, Reye, R. Zalacain, A. Capelastegui, J. Aspa, L. Borderías, J.J. Martín-Villasclaras, S. Bello, I. Alfageme, F.R. de Castro, J. Rello, L. Molinos, J. Ruiz-Manzano, 2012, Initial management of pneumonia and sepsis: factors associated with improved outcome, European Respiratory Journal, vol. 1, no.39, pp: 156-162; DOI: 10.1183/09031936.00188710. Nursing and Midwifery Board of Australia (NMBA), 2010, National competency standards for the registered nurse, Melbourne, NMBA. Ramirez J & Anzueto A, 2011, Changing needs of community-acquired pneumonia, J Antimicrob Chemother, vol. 66, no. 3, pp: iii3-iii9. Schellack B & Schellack, G, 2015, Hospital-acquired pneumonia and its management, S Afr Pharm J, vol. 82, no.1, pp: 26-32. Steel H, Cockeran R, Anderson R & Feldman C, 2013, Overview of Community-Acquired Pneumonia and the Role of Inflammatory Mechanisms in the Immunopathogenesis of Severe Pneumococcal Disease, Mediators Inflamm, vol. 13, no, 13, pp: 1-20. Watkins R, Lemonovich T & Akron M, 2011, Diagnosis and Management of Community-Acquired Pneumonia in Adults, Am Fam Physician, vol. 83, no. 11, pp: 1299-1306. Zafar M. (2016) A Case Study: Pneumonia, Occup Med Health Aff , vol. 4, no. 242, pp: 1-8.. Read More