Assessment and Management of Pneumonia by Extended Care Paramedics - Case Study Example

Case Study: Assessment and Management of Pneumonia by Extended Care Paramedics Student’s Name Institutional Affiliation Case Study: Assessment and Management of Pneumonia by Extended Care Paramedics Extended Care Paramedics (ECP) are tasked with seeing and treating some patients at the pre-hospital set-up (Finn, et al., 2013). Patients and their carers are saved the disruption that comes with a hospital trip. With reduced workload at the ED, general practitioners service providers at the ED shall be better placed at offering more comprehensive and quality health care services to deserving patients (Evans, McGovern, Birch & Newbury-Birch, 2013). Among the conditions that can be managed by ECP include non-severe community acquired pneumonia with lower PSI scores. The ECP has to have relevant assessment knowledge and skills to conclude a comprehensive assessment of a patient with pneumonia. Respiratory Assessment First, the patient shall be informed and familiarized with the felicitous breathing technique and the position that she shall be expected to sit during assessment using various technique (Debbie & Tara, 2010). In particular, examination of the posterior thorax through auscultation may require special positioning to enhance the surface over which auscultation can be done (Jarvis, 2012). The ECP shall be expected to ensure that the patient is secure in a quiet well-lit room. The patient’s privacy shall be observed by covering areas such as her breast and chest when such areas, or the anterior thorax, are not under examination (Debbie & Tara, 2010; Jarvis, 2012). The examination shall proceed systemically commencing with inspection, then palpation and percussion and finally auscultation. Inspection Inspection gives information regarding significant elements such as the configuration, integrity and symmetry of the thorax, the skin physical appearance and the respiration pattern (Ali & Moore-Gillon, 2012). The appearance of the skin may aid in identifying the nutritional status of the patient that may be significant when initiating treatment for the patient as malnutrition is associated with decreased immune function that might affect treatment outcome (Saunders & Smith, 2010). The thoracic configuration shall be inspected for any asymmetry where similar paired anatomical body parts shall be compared. A common segment inspected in the thorax is the size ratio of the anteroposterior diameter to the transverse diameter. This ratio ranges from about 1:2 to 5:7 and any value outside this limit may be indicative of an underlying abnormality (Anthony, Singham, Soans & Tyler, 2009). Barrel chest, common in respiratory tract diseases such as asthma, silicosis, emphysema, panbrochiolitis, chronic bronchitis and COPD, is characterized by prominent sternal angle and ribs appearing horizontal (Anthony et al., 2009). Other deformities that can be elicited on inspecting the thoracic configuration include chicken chest, non-uniform thoracic retraction and spinal deformities that include lordosis and kyphosis (Kinali, Main, Mercuri & Muntoni, 2007; Ali & Moore-Gillon, 2012). The respiration pattern is examined by observing the rhythm, rate and volume of breathing in addition to the movement of the ribcage and that of neck muscles that can be used as accessory muscles of respiration. The latter include upper trapezius, sternocleidomastoid and the pectoralis major whose involvement in respiration indicates labored breathing (Springer, 2012). Intercostal space retraction especially during inspiration may be suggestive of air inflow hindrance. If expiration is excessively prolonged, it may suggest outflow impedance (Springer, 2012). The patient has a normal resting respiratory rate of 18 resps/min as a normal resting adult has a rate of between 12 to 18 breaths/min in a regular unlabored pattern (Creticos et al., 2008; Springer, 2012). Abnormal breathing patterns may include Cheyne-Stokes respiration, Kussmaul breathing and Biot breathing that commonly indicate congestive heart failure or uremia, metabolic acidosis and impending respiratory failure respectively (Springer, 2012). Palpation It is a tactile form of examination where the chest can be assessed for various parameters including asymmetry, crepitus, diaphragmatic excursion, tenderness and fremitus (Springer, 2012). Other possible parameters that can be examined include the tracheal position and the expansion of the thorax. The skin including its underlying structures and subcutaneous tissues of the anterior chest, left and right lateral chest and the posterior chest shall be palpated (Springer, 2012). The thoracic expansion is assessed from the anterior to the posterior chest while ascertaining the symmetry and extend of the expansion of the thorax as patient breathes quietly and deeply (Jarvis, 2012). Crepitus may be felt when the chest wall is superficially palpated using a fingertip. It signifies presence of subcutaneous air – a common indicator of pneumothorax (Springer, 2012; Duff, 2007). The patient shall then be asked to vocalize familiar words repeatedly such as numerals as the patient’s thoracic wall is palpated. The vibration perceived on palpation is termed tactile fremitus. The sound is decreased over areas of increased air or fluid as in pleural effusion and magnified over areas of the lung with increased tissue density like in consolidation (Duff, 2007). Tracheal deviation can also be assessed via palpation and the findings can augment the diagnosis identified earlier. The index finger shall be used to palpate the trachea at the suprasternal notch. If the spaces bordering the trachea are found to be unequal, it indicates a lateral tracheal deviation that may be caused by conditions such as pleural effusion, tension pneumothorax and unilateral emphysema (Mcgee, 2012). Percussion This technique is useful in identifying areas of the lungs with high density of tissues or consolidation and lung areas that are well aerated and tympanic (Springer, 2012). In addition, the extent of an abnormality in the lungs can be identified, and visceral organs abnormality can be determined using this technique. Both the posterior and anterior chest shall be percussed in a left to right and right to left movement. Auscultation The patient shall be in a sitting position as this technique is carried out, and she shall be expected to exhale and inhale deeply through the mouth. Breath sounds (BS) shall be heard on auscultation some of which may represent abnormalities. Bronchial BS may indicate consolidation in the tissues of the lungs as in pneumonia while absent or attenuated BS may be suggestive of pleural effusion or pneumothorax (Duff, 2007; Springer, 2012). Other sounds that may be heard during auscultation include wheezes, crackles, rhonchi and stridor (Springer, 2012). Pneumonia Severity Index (PSI) Class 1 Patients with community-acquired pneumonia (CAP) can be grouped into five different classes based on a patient’s risk of morbidity and mortality (Shah et al., 2008). A patient should be less than 50 years and should have never heard medical conditions that include congestive heart failure, neoplastic diseases, cerebrovascular diseases, liver disease or renal disease, and the mental status of the patient should not be altered; systolic blood pressure should be less than 90mmHg with a pulse and respiratory rate of at most 125 and 30/min respectively, and a temperature of between 350C and 400C to be classified as a PSI class 1 patient (Aujesky & Fine, 2008; Jacobs, Goud & Shaikh, 2009). Preconditions for ECP Patient Management and Admission at Silver Chain The patient meets the criteria for classification in PSI class 1. A patient in this class may be managed at home by an ECP only if her condition does not aggravate suddenly. Moreover, a patient shall not be managed at home if on assessment the patient is confirmed to have pleural effusion in the lungs, or she is found intolerant to salient oral medication, or if the patency of her airways degenerate suddenly (SA Ambulance Service, 2008). If the patient’s condition, even though in PSI class 1, excludes an ECP from managing such patient from home, the ECP may refer the patient to a suitable institution that provides medical services such as Silver Chain. The latter provides hospital-in-the-home services where the patient can be efficiently managed from her home. Silver Chain has its clinical protocol that guides the admission of patients with CAP, that includes a PSI score of less than 1. The institution may exclude admission if the patient has been ascertained pregnant, or her condition worsens demanding the utilization of supplemental oxygen, if she is immunocompromised, or her condition progresses past a PSI score of 3 or a CORB score of more than one (Silver Chain, 2013). Patient Treatment The treatment may be treated empirically by an ECP using medicines that include 500mg of oral cefuroxime taken twice daily for a minimum of five days plus clarithromycin 500mg taken twice daily or doxycycline 200mg on day one and 100mg on the following days of treatment (Maxwell, Mcintosh, Pulver & Kylie, 2005). However, doxycycline shall be excluded if the patient is pregnant (Maxwell et al., 2005). The fever, pain and possible inflammation shall be relieved by use of antipyretics, analgesics and anti-inflammatory agents such as NSAIDS (Richards et al., 2005). Increased oral fluid intake shall be recommended to replace any lost fluid. Clinical monitoring shall be paramount to monitor the progress of the patient’s recovery and if within one to three days the patient does not show any signs of improvement or her conditions worsens, a reassessment of the condition may be necessary (Maxwell et al., 2005). If the patient shows any anxiety, reassuring her of her recovery shall be necessary. Moreover, she shall be advised to rest and avoid activities that are known to trigger her asthmatic attack that may consequently worsen her condition. Conclusion Emergency medical services provided by ECP include a ‘see and treat' initiative depending on the condition of the patient. Therefore, ECP help to ease congestion in the ED. CAP with a PSI score of at most 1 can be managed by ECP at home, but higher PSI scores necessitate transport to ED of the nearest appropriate hospital. References Ali, F.R. & Moore-Gillon, J.C. (2012). Basic systems. Respiratory system. In M. G. Drake (Ed.), Hutchinson's clinical methods, An integrated approach to clinical practice (23rd ed., pp. 147-164). Chatswood, NSW.: Saunders Elsevier. Anthony, M.P., SIngham, S., Soans, B. & Tyler, G. (2009). Diffuse panbronchiolitis: not just an Asian disease: Australian case series and review of the literature. Biomedical Imaging and Intervention Journal, 5(4), e19-e24. Aujesky, D. & Fine, M.J. (2008). The pneumonia severity index: a decade after the initial derivation and validation. Clinical Infectious Disease, 47(suppl 3), S133-S139. Cretikos, M.A., Bellomo, R., Hillman, K., Finfer, S. & Flabouris, A. (2008). Respiratory rate: the neglected vital sign. The Medical Journal of Australia, 188(11), 657-659. Curtis, K. & Ramsden, C. (2011). Emergency and Trauma care for nurses and paramedics. Chatswood, NSW: Mosby Elsevier Australia. Duff, B. (2007). The impact of surgical ward nurses practicing respiratory assessment on positive patient outcomes. 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Retrieved from http://www.saambulance.com.au/LinkClick.aspx?fileticket=7dKFTy8RTL0%3d&tabid=82 Saunders, J. & Smith, T. (2010). Malnutrition: causes and consequences. Journalof the Royal College of Physicians, 10(6), 624-627. Silver Chain. (2013). Clinical protocol for community-acquired pneumonia. Retrieved from http://www.silverchain.org.au/assets/WA/Health/Home-Hospital-Protocols/Clinical-Protocol-CAP-CC-CP-004.pdf Shah, B.A., Ahmed, W., Dhobi, G.N., Shah, N.N., Quibtiya, S. & Haq, I. (2010). Validity of pneumonia severity index and CURB-65 severity scoring systems in community-acquired pneumonia in an Indian setting. The Indian Journal of Chest Diseases & Allied Sciences, 52, 9-17. Springer, J.Z. (2012). Pulmonary examination technique. Retrieved from http://emedicine.medscape.com/article/1909159-technique Read More