Acute Pneumonia and Critical Nursing - Essay Example

 Critical care nursing is the special case of nursing that deals with patients facing light threatening problems and it is the critical care nurse whose responsibility is to ensure that the critically ill patient and his or her family receives optimal care. In this nerve racking setting, it is the duty of the nurses to assist and take care of the patient, which includes complex assessments of the patient, high intensity therapies, medical intervention and continuous nursing care. Therefore the critical care nurse is expected to possess specialized knowledge, skill and experience to provide the best care available and act as an advocate for the patient. In this case, the special care and knowledge needed helped the nurse assist, diagnose, and treat the case of acute pneumonia that the patient developed. Mr. Jones Stromenger (J.S) age 70 was admitted to the emergency care unit. He was complaining of acute pain when he coughed or when he took deep breaths. He had experience shortness of breath when he walked more than 20 feet. On admission he was recorded to have high fever accompanied shaking chills, sharp pleuritic chest pain, headache and sweaty and clammy skin. When he coughed he produced rusty sputum with mixture of blood. His skin was showing mild tinge of blueness and he was reported to have nausea and vomiting. The temperature was >38.6 degree c with more than 25 breaths per min, systolic BP 100breaths per min. on laboratory finding, arterial pH was less than 7.35, blood urea nitrogen > 30 mg/ dl and sodium < 130mmol/dl and PaO2 < 600mm Hg. On pulse oximetry the patient showed hypoxia and arterial blood gas exchange showed slower oxygenation so breathing tube was introduces and adequate oxygenation was given. The age was the critical factor and the patient was considered to be in Risk class 1 that favored the admission of the patient into the critical care. (Almirall etal., 1999) As the first level of emergency care the patient was made to undergo physical examination and chest x-ray. A Blood test and a sputum culture were also ordered. When given a physical examination it was found that the patient had a fever, increased respiratory rate, low blood pressure, fast heart rate and sinus problems. The lungs were auscultation, with stethoscope crackling sounds found, and an increase loudness of whisper speech showed the areas of lungs that were stiff and full of fluids – “consolidation “. This preliminary finding let to the undoubtful diagnosis of pneumonia, though the type was left to be determined later. As an initial treatment strategy an empirical medication was started. Assessing the vital sign pO2, general antibiotics and oxygen supplement were given. Heavy hydration also started. The first dose of antibiotic is provided within 4 hours, pO2 maintain at greater than 92% and respiratory rate at less than 30. Also the antipyretics and analgesics as acetaminophen – Typophenol and Ibuprofen – Advil are started. No cough suppressant was prescribed as the cough would clear the sputum. Smoking and alcohol were banned as they may hurt the body’s ability to fight the infection. The samples sent for complete blood count that included the number and types of white cells present that could possible help to determine the type of infection as viral bacterial or fungal infection. A blood culture was taken to try to identify the organism, a pulse oximetry to measure the amount of oxygen in the blood. An arterial blood gas was used to measure the concentration of substances as oxygen, carbon dioxide and pH. These tests helped to determine the level of additional oxygen or mechanical ventilation to be provided. Also a sputum culture was used to identify the organism and a chest x-ray was administered to identify the pattern of pneumonia. In case of suspected condition CT scan, bronchoscopy – a procedure that helps to examine the entire respiratory track and helps to collect samples of fluids and tissue which on biopsy may revel the organism. The general antibiotic mentioned here usually involves penicillin. If the patient is allergic he may be given erythromycin. However, in America drugs as azithromycin, clarithromycin, and other fluroquinolones are also used in these types of cases (Aspa etal., 2006). To further decide the course of treatment the medical history of the patient was collected. The patient, Mr. J.S, was from a lower economic status group who had worked in a congested pulp mill. He had been a heavy smoker and very frequent alcoholic. Three months back he had been admitted in the hospital and was under treatment for viral infection for a week and then was discharged. He had no reported conditions of AIDS or asthma, Cystic fibrosis, sickle cell anemia, lymphoma, leukemia and emphysema. He was reported to be moderately diabetic. He had no reported family history of pneumonia (Metlay etal, 1997). The risk of pneumonia increases with age as it widely seems to occur in aged population or in children below five years. Elderly people are found to have less effective mucociliary escalator and also reported to have less active immune system which causes these age groups to have more of a risk of contracting pneumonia. Adding to this; cigarettes smoke that is inhaled continuously has also been found to interfere with the ciliary function, inhibiting the macro phage function. Alcohol is another factor that has been reported in various studies to interfere with the function of epiglottis. A weak epiglottis in turn needs to a leaky seal on the trap door that leads to high charge of contamination by swallowed or regurgitated content. Alcohol is also found to interfere with normal cough reflex thus decreasing the chance of clearance of unwanted substance from the respiratory track. (Fine etal.,1997) These findings from the medical history rules out the presence of any hereditary causes, but at the same time favors the presence of pneumonia that might have been caused due to micro organism. These organisms might have been obtained from hospital setting or community setting. The community acquired pneumonia is infectious pneumonia in a person who has not recently been hospitalized, the common cause being Streptococcus pneumoniae. The hospital acquired is obtained as a nosocomial infection from hospital or due to things used as endotracheal tube, intubations etc. Here the patient is a likely candidate on both the sides, due to the fact that the patient was recently admitted into the hospital. Pneumonia is an infection of the lungs that is caused by any class of micro organism that can infect human beings, ranging from bacteria, amoeba, virus, fungi and parasite. In the Unites States pneumonia is considered to be the sixth common disease that leads to death and out of 2 million Americans developing pneumonia each year, 40,000 to 70,000 of them die from it. (Arias & Smith,2003) The patho physiology of the disease is caused by the invasion of the lungs by micro organisms which trigger the immune system response. Pneumonia is a serious infection of the lungs that causes the air sacs in the lungs to fill with puss and other liquid. The bacteria may enter the lung as an air borne droplet inhaled or could reach the lung through the blood stream. In this particular case the micro organism might have entered through respiratory pathway as no other infection is reported. Once inhaled the bacteria’s invades the space between the cells and alveoli through connecting force. This invasion triggers the immune system which tries to fight the bacteria by sending the neutrophils to the lungs. The neutrophils in turn acts by engulfing the pathogens and releases cytokines that causes generalize activation of immune system. This is the reason for the fever, chills, and fatigue and increase neutrophil count scene in the patient. This neutrophil, along with that bacteria and the fluid from surrounding blood vessel fill the alveoli, interrupting oxygen transportation. In this patient there is a chance that the infection could be either one, a bacterial or a viral infection. (Mark H. Beers & Robert Berkow, 1999) In this case the bacteria might have been asymptomatically obtained from the previous hospital admission- nosocomial infection or it also may have been strongly associated with the viral infection. It is possible that it is a viral infection. The increases that the attachment of the pneumococcus caused to the alveolar epithelium that in turn would have affected the alveoli caused the infection to spreads through the pores of Kohn and form the consolidation. The chief way of differentiating pneumonia is through the results obtained from sputum, plural fluid and blood culture and through broncoscopy. The sputum specimens are subjected to Gram strain and to pin point the particular caustic organism. Also, a polymerized chain reaction can be used to identify the chain reaction. The primary possibility that can be ruled out is chiefly the influence of varicella. The patient was admitted in a season that wasn’t common for influenza. While pneumonia on x-ray shows the pattern of bilateral with interstitial rather than lobar in filtrates, this patient’s x-rays shows lobar in filtrates. No continuous that rules out varicella, lack of any travel history rules out other type of viral infection. Since the patient was not on any immunosuppressant the Cyto megalo virus is also ruled out. Fungal organisms are also ruled out due to the absence of lesion (Ray, C. George,1994). The preliminary procedure of pinpointing the causative organisms as bacteria is now out of the way. However, the patient is not showing much improvement with initial general treatment. The next stage of treatment would be to go in for a chest x-ray, take a sputum culture and other organics specific tests. The Chest X-Ray revealed that there were consolidation seem in the lobar portion of lungs that was typical to bacterial infections. But to rule out any ambiguity, sputum culture and blood culture were taken. Since the X-ray revealed Lobar Pneumonia, the bacterial infection was confirmed. The next step was to differentiate whether it is typical or a-typical pathogens. The typical organisms include the S pneumoniae (pneumococcus) and Haemophilus and Staphylococcus species and the atypical pathogens may be Chlamydia pneumoniae, Mycoplasma pneumoniae, and Legionella pneumoniae.the atypical was ruled out based on the pattern of extra pulmonary organ involvement and later by the specific antigen test. The presence of patient in overcrowded environment and recent hospitalization favored Staphylococcus pneumoniae. (Syrjala etal.,1998) As the sputum cultures generally take at least two to three days at least to bring results, a blood sample was cultured to look for infection in the blood. With the bacteria identified, the blood is then tested to see which antibiotics will be most effective. A complete blood count showed a high white blood cell count, indicating the presence of an infection or inflammation. Blood tests were also done to evaluate kidney function (important when prescribing certain antibiotics). Also the blood sodium level was measured, which was low due to extra anti-diuretic hormone produced when the lungs are diseased. Specific blood serology tests for other bacteria (Mycoplasma, Legionella and Chlamydophila) and a urine test for Legionella antigen were done and those were ruled out. Respiratory secretions can also be tested for the presence of viruses such as influenza, respiratory syncytial virus, and adenovirus.( Bartlett &Mundy,1995) These results show that the patient is not very well responding to initial treatment and needs a specific antibiotic treatment. This shows that the patient has a risk of developing sepsis and rapid treatment is essential in the patient’s care. After doing a preliminary gram stain, the sputum examination and blood culture is completed. The antigen specific test and blood culture showed the Staphylococcus pneumoniae as the causative organism. Further the chest radiograph showed a segmented or lobar focal opacity with air bronchogram, a typical feature of Spneumoniae. The samples for the culture and examination were obtained by Bronchoscopy, Transtracheal aspiration and Thoracentesis ( Balleste etal.,2004). As a further additive, arterial blood gas is tested to examine the level of oxygen in the blood. Here the patient showed less than 90%, which indicated an impeding hypoxia. This also helped to determine the arterial blood gas, and because of this the oxygen supplementation was continued. The histology showed the pneumonia has progressed over three days and the leukocytes had invaded the alveoli, with the erythrocytes lysed. Further the epithelial cells had degenerated, leading to "gray hepatization." This may be due to the release of toxin by the dying pneumococci that caused the further damage. The pneumococci are opsonized by leukocytes and begin to be cleared. Also seen was a formation of jellylike yellowish-colored exudates. (Bartlett etal., 1998) The treatment becomes very important because as always there is great risk of bacteria traveling from the infected lungs, through the blood that could result in serious progressions such as septic shock that could end up in low blood pressure, resulting in multiple organ damage involving, brain, kidney and heart. Apart from this the bacteria could travel through the pleural fluids to the chest wall resulting in emphysema. Some additional complications also may include respiratory or circulatory failure. It is also found to cause respiratory failure by triggering acute respiratory distress syndrome (ARDS), which results from a combination of infection and inflammatory response. The lungs quickly fill with fluid and become very stiff. This stiffness, combined with severe difficulties extracting oxygen due to the alveolar fluid, create a need for mechanical ventilation. Sepsis and septic shock are potential complications of pneumonia. Sepsis occurs when microorganisms enter the bloodstream and the immune system responds by secreting cytokines. Sepsis most often occurs with bacterial pneumonia; Streptococcus pneumoniae is the most common cause. (Crnich & Proctor,2004) In treating the patient three points were kept in mind, does he have any co existing illness, is he old, has severe illness at the time of admission. Here the patient was old and serious at the time of admission and had many negative facts on history. So a vigorous treatment care was initiated. As per the guidelines or recommendations of the American Thoracic Society (1993) the treatment with antibiotic is followed. As the patient didn’t respond to empirical treatment after evaluating the lab finding and bronchoscopy study and with the retrospective study of case history, the specific antibiotic care was tailored. The first choice of antibiotic was IV dose of Antipseudomonal fluoroquinolone (e.g., ciprofloxacin) plus antipseudomonal beta-lactam (e.g., ceftazidime, piperacillin- tazobactam, carbapenem) or aminoglycoside (e.g., gentamicin, tobramycin, amikacin). With the oximetry reading then a non invasive breathing was advised by the critical care consultant. Also the health of the patient was maintained with proper rest, void of smoking and alcohol, with plenty of fluids , IV fluid to maintain pressure,(when oral resumed the IV was stopped), and nutritional supplements as vitamin C, bio flavanoids, Vitamin A, beta Carotene and Zinc. Thus within 72 hours of antibiotic, the patient showed marked improvement, the blood oxygen level resumed to normal hence external oxygenation was removed, and in 8 days the cough cleared along with the crackle sound of auscultation. Then again the chest radiograph and culture test were done to show the marked improvement. Also the patient education was provided then and there to explain about the treatment principles of diagnosis and treatment and expected patient’s outcomes. On discharge the preventive and points to be taken care of was also provided, as change in life style (Carratalaetal.,2006) The nursing steps in this particular case involved subjective data and objective data. Here the diagnosis of pneumonia was done with the difficulty in breathing, abnormal sound breath, rate and depth of respiration, effective cough and sputum. The next step is setting a goal for nursing, here it is reverse of diagnosis, i.e. the expected outcome would be clear or normal breath, no wheeze or crackle sound, respiration rate at 14-18 per min with no cough. After the goal is set the nursing intervention is did. Thus on day 1, the nursing assessment include the assessment of vital signs, with the spO2 maintained at saturation level of >92 %, IV intervention studied and also the lung sound for every 4 hours with continuum assessment of pain and risk for aspiration. As nursing intervention, apart from medication, that patient was encouraged to cough and deep breathe every two hours with incentive spirometry and mouth care. The feeding was given in 6 small portions with adequate fluid. The same strategy was followed with adjustments based on improvement of particular aspect. In general IV fluid was removed on day 2 and patient was advised to take ample fluid of 1000 cc per day and the breathe and cough exercise was followed. Ample rest was provided and ambulatory movements were encouraged until the patient recovered completely. (Fine etal., 1996) The first nursing diagnosis pertinent to J.S case was the patient’s blood oxygen level. The intervention in this case was to regularly monitor blood O2 once every two hours and adjust the external oxygen flow. When the blood oxygen level resumed to normal, the external oxygenation was stopped. The next step in nursing intervention was to maintain the fluid level in the body. With the initial stage of the patient not being able to takes oral fluids, intravenous fluid support was provided, with a track of sodium level. Then as the day progressed, the patient was advised to take 100 CC fluids per day, removing the intravenous fluid support. The next concern was the regular process of making the patient to breathe deep and cough regularly, at the basis of two hours. This helped in clearing the sputum and congestion. Thus the critical care setting involves the roles of physician, nurses, technician etc. the critical care nurse is here expected to mediate care considering the overall physical, mental , psychological , spiritual nod familial expectations, with the main aim as the care of patient and their well being. The patient was diagnosed with acute pneumonia, and due to the nursing interventions, the patient was able to recover and receive the proper medications. Looking back at the case study, the outcome of the diagnostic went quite well, and even with the patient’s previous history, no major complications due to the process were found. The treatment went quite well, and the overall study of the patient and disease helped the patient overcome the disease with the proper treatment. References Admirals J, Bolibar I, Balanzo X, Gonzalez CA. Risk factors for community-acquired pneumonia in adults: A population-based case-control study. Eur Respir J. 1999; 13:349. Arias, E., and B. L. Smith. 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