Nursing Assessment of Steven Smith Presenting with Bacterial Pneumonia - Case Study Example

Nursing assessment of Steven Smith presenting with bacterial pneumonia Name Nursing XXX Professor XXX Date XXX Introduction Steven Smith, 32, is diagnosed of having bacterial pneumonia. His respiratory rate of 28 respirations/ minute and lowered oxygen saturation level is indicative of respiratory distress induced by the exudates due to infection. The acute pain is on account of the impaired gas exchange. His temperature of 38.1 degree Celsius is indicative of the level of spread bacterial pneumonia has undergone. Clearly Steven Smith is in a state of hypoxia, and 30 cigarettes a day habit has compromised his lung capacity to fight the symptoms induced by bacterial pneumonia. The respiratory distress which is more pronounced by coughing and deep breathing is a manifestation of degree of lung involvement. Also, Steven’s face seems pale, and so as part of the nursing assessment and care two priority problems facing the nurses is to ease respiratory distress and enhance oxygen transport to him. Interventions on the first problem Respiratory distress Steven is in a state of respiratory distress, indicated by his 28 respirations/ minute and confirmed by his observation on the chart that reads moderate recession/working hard, decreased air entry in both lung bases, scattered coarse crackles and wheezes upon auscultation. This must form one of the primary concerns for the nurses as pneumonia has been seen leading to acute respiratory distress syndrome (Burad J et al, 2012). Steven’s respiratory rate is almost twice as much as is for a normal adult of his age, which must be 12 to 18 respirations/ minute. Low oxygen levels and rapid breathing are the first signs and symptoms of acute respiratory distress syndrome (Aboab J et al, 2006). Addressing this becomes a nursing priority also because of the fact that if this is left unattended it could lead to other possible complications like lung scarring, a collapsed lung, and blood clots. Evidence suggests that this condition is a direct consequence of pneumonia and is associated with significant mortality and morbidity (Cortés I et al, 2012). In order to ascertain the extent of the problem in its entirety, Steven’s respiratory pattern and general appearance would have to be observed carefully. This will help in determination of his level of fatigue, presence of tachypnea or dyspnea and presence of cyanosis (Scott JA et al, 2012). Vital signs will have to be assessed again since the previous ones were of 2 hours back. It is important to assess these signs for weakness, rapidity, thready pulse, and blood pressure changes (Musonda P et al, 2011). Chest will have to be palpated for tactile fremitus and areas of consolidation. This can be done by percussing the chest over areas of consolidation for dullness. While auscultating Steven's breathing, crackles, rales, wheezes and ronchi will have to be listened to carefully. "E" to "A" changes will have to be noted and so will have to be the pectoriloquy whispers. Also, Steven will have to be observed for anxiousness as pneumonia patients are often anxious and fatigued (Alexandroaie B et al, 2011). Acute pain due to persistent coughing makes them distressed. Colour of purulent discharge, skin and nails will have to be observed. The rationale behind this is to check for any indications leading to systemic hypoxemia since cyanosis on skin, mucous, and even ears is an indication of this. Confusion, nervous irritability, and somnolence are indicative of cerebral hypoxia. Two priority nursing interventions Generally antibiotics are used to treat bacterial pneumonia (Girdhar A et al, 2012), and Steven has already been prescribed intravenous therapy N/saline 0.9% 1000ml/12hours with intravenous antibiotic therapy. If Steven's condition seems to be worsening, mechanical ventilation and intubation cannot be ruled out. IV fluids are already running to replace fluid loss and antipyretics can be given to control fever. Postural drainage and percussion can be used in order to help him in expectorating secretions (Branson RD. 2007). Nurses have to ensure that he is encouraged to use deep breathing exercises every now then and he coughs out the secretions. Unless contraindicated, he can be encouraged to take fluids orally. If Stephen's inability to cough up secretions is perceived, orotracheal suction or nasotracheal suction will have to be performed. This is important in the sense that it would help him keep airways open to an extent. He must be turned to bedrest position to keep airways open and free of secretions with head elevated to a minimum 45 degrees. An ideal thing will be to ask Stephen to reveal the position that he perceives does ease his breathing. Another option would be to turn him to upright position, in which pillows can be used to support arms, or adjust him to lean forward position with overbed table used to rest his arms. The primary goal is to de-stress his lungs and if that means involving and educating him in the process, it must be done. If intubation is required it is better to bring him first into confidence so that he understands and accepts the relevance of the procedure. He can be revealed the extent to which he is likely to feel better by coughing exercises, bed rest and deep breathing (Yu H, 2011). Nursing interventions in this case can be grouped either into independent or dependent interventions. The former the ones that nurses can and must employ on their own like positioning Steven with head on mid line and with slight flexion, auscultating his chest, provide back and chest clapping with vibration, address patient's "white coat syndrome" which could hold true for Steven since he seems to be passing through a lot of distress-driven anxiety. The rationale for these would be to provide him with maximum lung excursion and unobstructed airways; monitor abnormal breath sounds; chest physiotherapy so that secretions could be loosened; and developing a rapport with him to provide mental support and trust. Dependent interventions, on the other hand, would be to follow what physician has recommended, use broncholdialtors (Tashkin DP et al, 2008) and antipyretics accordingly, continue antibiotic therapy to contain infection and place Steven on normal saline as recommended. Bronchodialators can be administered through nebulization which, by far, stands out as a preferred method of administering this class of medicines for effective, instant, and reliable method of easing breathing load and expectorating secretions (Watts AB, 2008). Interventions on the second problem Enhance oxygen transport Steven is suffering from bacterial pneumonia as a result of which his air sacs in the lungs are filled with pus and other secretions (Driver C, 2012) which, as enumerated above, are the reasons for his distressed breathing. Another potential complication of the same is that these accumulations in the lungs interfere with his oxygen transport -- there is too little oxygen going out to his body for replenishment of his cells resulting in their improper functioning. Weak metabolism at the cellular level, on account of paucity of oxygenated blood, compromises his other organs including vitals. In case of pneumonia this is a potentially dangerous situation as low oxygen levels in the body and particularly in the brain can trigger a hypoxic shock. Arguably, given Stephen's condition, pneumonia has affected his lungs in two ways – one on the lobar front and another on the bronchial one; respectively this is termed as lobar pneumonia and bronchial pneumonia. The direct consequence of this is low hemoglobin count in the blood which further lowers erythropoietin synthesis. This is a must for red bone marrow which produces red blood cells. A establish this further if investigations are done on erythrocyte volume, it would show a value below normal since there is overall deficiency of oxygen moving through his system; when iron portion binds with oxygen it forms oxyhemoglobin. But since that is not the case with Stephen whose reports show low oxygen saturation levels, his leucocyte count would be far higher than normal, further weakening his body's immune system on account of reduced phagocytosis activity (Shapovalov KG et al, 2011). Since pneumonia is an inflammatory condition, it stiffens lung tissues (De Luca D et al, 2008). This adds to the host of other reasons that decrease lung compliance and increase breathing load. Steven's chart clearly mentions that he is 'working hard'. On a nursing front, it calls for immediate nursing attention and intervention since a physiological shunt is caused by fluid-filled alveoli. Consequently there are some unventilated portions of lung tissue through which venous blood passes. This blood returns unoxygenated to the left atrium setting up a vicious chain of unoxygenated blood being transported to body and in fact accumulating the transport load of unoxygenated blood. Nurses must have a realisation that this is the beginning of a very risky path ahead for the patient since it is here arterial oxygen tension falls. As soon as that happens in case of Steven he would start showing hypoxemia signs and symptoms. If he does not get the required oxygen supply, he could even go into a septic shock or a respiratory failure. Continued depleting levels of oxygen can aid infection in spreading to other parts through bloodstream and cause pericarditis, endocarditis, bacteremia and even meningitis (Tudose C, 2010). Two priority nursing interventions The most urgent intervention that can be taken up by nurses is put Steven on supplemental oxygen which minimise the risk of hypoxemia by aiding in ventilation. It is a general practice to use face masks for supplemental oxygen but since Steven would require coughing from time to time a face mask might impede in the process and actually make him uncomfortable. Steven's SpO2 level is 92 at room air; if not optimised and its starts drifting, as soon as it touches 90 and further below, it would directly mean hypoxemic respiratory failure for Steven. In other words it would, in nursing parlance, be "oxygen failure". Nursing intervention's immediate and overriding aims are to re-establish arterial oxygen levels adequately and expulsion of excessive carbon dioxide (Zuwallack R, 2007). Nurses can also get an arterial blood gas analysis to ascertain PaO2 levels; anything less than 60mmHg is alarming. Expert nursing intervention understands that supplemental oxygen therapy works on accomplishing three goals, which are: decrease breathing workload, address hypoxemia, and decrease mycocardial load. Normally it is recommended for any patient with slight or more respiratory distress, and in case of Steven it is a must to be resorted to. One of the four methods of administering supplemental oxygen can be used in his case; each offering it advantages and disadvantages. These are face mask, nasal oxygen insuflation, oxygen cage, and intratracehal route. While face mask is simple, Steven may not tolerate it. And since face masks need to be attended all the time, one nurse has to be dedicated for the purpose, which may not be possible. Oxygen cage does not apply to this case and intratracheal tube is not viable too since it requires sedation first and continuous monitoring later. That leaves nurses with nasal oxygen, which is suited best for Steven since it would provide him more freedom of movement. But it must be a part of the nursing intervention to be vigilant when it is being used on Steven since excessive flow from it might cause gastric dilatation. Conclusion Steven’s case is an interesting one as it presents with a typical bacterial pneumonia pathophysiology. While the drug therapy is the mainstay of his recovery, undermining the importance of proper nursing intervention would constitute gross negligence. At the same, and based on the vital parameters that Steven presents with, the case calls for an expert twin-pronged approach to one, relieving him of the respiratory distress and expulsion of secretions and two, saturate him with oxygen in order to optimize his depleting oxygen levels. This paper has presented some approaches and justified why the same must be used for while others must not be. References Alexandroaie B, Huţuleac L, Costin G, Constantinescu G.(2011). Diagnostic approach of pneumonia in an elderly patient with comorbidities--case report. Rev Med Chir Soc Med Nat Iasi. Jul-Sep;115(3):781-7. Aboab J, Jonson B, Kouatchet A, Taille S, Niklason L, Brochard L. ( 2006). Effect of inspired oxygen fraction on alveolar derecruitment in acute respiratory distress syndrome. Intensive Care Med. Dec;32(12):1979-86. Epub 2006 Sep 22. 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