Case Summary
Tom went to the ER with signs and symptoms of community-acquired pneumonia in this case study. Coughing and shortness of breath were the most common complaints. The goal of this research was to provide a framework for using the nursing process to establish a care plan for a patient while they were in the hospital. To evaluate his condition, a physical, psychological, and medical history examination was undertaken. These findings revealed the need to maintain appropriate oxygen exchange, establish regular breathing patterns, and maintain safety awareness. Finally, the long-term goal was to teach the patient about the causes and risk factors associated with his initial diagnosis of community-acquired pneumonia.
Pathophysiology
Pneumonia is a frequent pulmonary parenchyma infection that is now one of the most prevalent causes of hospitalization in the United States. It is divided into four types, according to Kasper et al. (2018): community-acquired (CAP), ventilator-associated (VAP), hospital-acquired (HAP), and care-associated (HCAP) pneumonia. Septicity in the lung alveoli marks the start of pneumonia caused by certain fungi, bacteria, and viruses (Kosutova & Mikolka, 2021). Inhalation of these airborne bacteria is a common method of infection, while self-infection can also occur in healthy people. Hemophilus influenza and pneumococcus, for example, are bacteria that live in the human airway and usually cause community-acquired pneumonia (CAP) (Kosutova & Mikolka, 2021). However, the lack of immunity is a risk factor for pneumonia.
Because they manage to elude the host’s physical defense mechanisms, infectious organisms capable of reaching the alveoli must have a high pathogenicity level. As a result, immune system cells like macrophages are overwhelmed. When infections enter the lungs, they cause alterations in the alveoli and bronchioles, which result in an increase in fibrin-rich exudate (Blomberg & Sharda, 2022). The rise in fibrin-rich exudate has the effect of filling alveolar gaps, both infected and uninfected, causing them to cling together and become airless. Furthermore, neutrophils increase as a result of the inflammatory response.
When germs reached the patient’s lungs by aspiration of contaminated oropharyngeal secretions, he was most certainly infected with pneumonia (Lanks et al., 2019). Inhaling pathogenic germs emitted by an infected individual by coughing, sneezing, or talking might have infected him. Infections from other organisms can also move from the circulation to the lungs. The patient became infected as a result of his immune system being overburdened by the virulence or quantity of infectious germs (Lanks et al., 2019). As a result, determining the origin of lung infection is critical for determining diagnostic and therapeutic options.
Once the bacteria have colonized the alveoli, the body’s immune and inflammatory systems are activated. Meanwhile, endotoxins are released by some bacteria, and the body responds with an antigen-antibody reaction. The antigen-antibody reaction and endotoxins cause inflammation in the alveolar and bronchial mucous membranes, leading to edema and congestion (Grief & Loza, 2018). Infectious exudate and debris eventually clog alveoli, interfering with gas exchange and ventilation, resulting in pneumonia. Miliary pneumonia, bronchopneumonia, lobar pneumonia, and interstitial pneumonia are the four types of respiratory illnesses that can occur (Grief & Loza, 2018). The type of infective organism determines the anatomical location, clinical process, and expression of the patient’s pneumonia.
In individuals with pneumonia, pleural inflammation is a common symptom. When the patient is in the Fowler’s or high-posture Fowler’s, it generates an acute localized discomfort that the diagnosing doctor may identify (Gunay et al., 2018). The doctor can report pleural inflammation if the patient has pain when taking a deep breath, coughing, or moving as directed by the doctor. When the patient takes a deep breath, the doctor may evaluate the distal airways and the capacity of the alveoli to expand appropriately; this is a risk for decreased gas exchange and atelectasis (Gunay et al., 2018). The patient may also experience weariness as a result of labored breathing. Fatigue and hypoxia are risk factors for reduced lung inflation.
Clinical Manifestations
Tom went to the emergency room with a cough and shortness of breath that had been becoming worse over the last few days. According to the Emergency Medical Service, oxygen saturation is at 90%. In reaction to the bacterial infection, the patient will develop symptoms of a higher-than-normal body temperature. Dehydration will occur as a result of the high temperature, causing fluid loss (Neill & Dean, 2019). Breathing becomes difficult, and discomfort from inflammation causes pain when breathing. It is possible that the discomfort will expand to the pleura (Neill & Dean, 2019). A productive cough with rust-colored sputum will be present, and the patient will be tired. The symptoms can range from a moderate cough to full-blown respiratory failure and acute respiratory distress syndrome if left untreated.
The initial clinical manifestations and symptoms of community-acquired pneumonia are clearly identifiable. Several respiratory illnesses have symptoms that are identical. The right diagnosis is critical in easing the patient’s symptoms, regardless of the form of pneumonia (Lee & Ryu, 2018). The doctor’s prescription will address the treatment and nursing care in a synchronized manner based on the diagnosis to guarantee that the infection is entirely reduced or weakened and the patient recovers (Chan et al., 2018). Clear nursing care recommendations should assist the nurse in the hospital and the caregiver at home in assisting the patient in remaining strong and hopeful that he will recover quickly.
Fever, sweating, cough, purulent sputum, dyspnea, tachypnea, and pleural discomfort are common clinical signs and symptoms. Various indications, such as percussive dullness, decreased or bronchial breath sounds, egophony, and crackles might be identified on a chest examination (Tiwari et al., 2022). In the aged, atypical indications and symptoms might be noted. Discomfort, weariness, mobility limitation, falls, or worsening cognitive impairment are examples of nonspecific symptoms (Schwarz et al., 2018). Fever or tachypnea, acute confusional episodes, dementia, or the presence of dysphasia are all common causes of volume depletion in the elderly. The Pneumonia Severity Index (PSI) and the CURB-65 are used to determine the severity of the condition (Maeda et al., 2021). Twenty factors are totaled together in the PSI to assign a patient to one of five risk groups.
A multitude of things must be considered before deciding on a treatment plan. The severity of the disease, the overall clinical picture, and specific patient characteristics should all be taken into account (Makhnevich et al., 2019). Close collaboration between microbiologists, infectious disease specialists, and local doctors caring for community-acquired pneumonia patients is encouraged (Tiwari et al., 2021). Cardiac, renal, gastrointestinal, and CNS side effects must all be closely monitored.
Nursing Management
Focused Assessment
Tom was in respiratory distress when he arrived at the ER. The patient enters with a cough and shortness of breath that has been growing worse for the past three days. On room air, EMS indicates saturation of 88%. There are no nasal flaring or retractions, and respirations are 20-24 per minute. The patient has a smoking history and pneumonia in the past. Respirations are steady and regular at 20 breaths per minute, with oxygen saturation at 98% on 2 liter nasal prongs. There are no retractions or auxiliary muscles engaged in this symmetric chest expansion. At the base, crackles and inspiratory and expiratory wheezing can be detected bilaterally. With thin, clear sputum, the patient has a nonproductive wet cough. The patient is awake and aware of time, person, and location. The patient grins frequently and keeps eye contact while pupils are equal in size, circular in shape, and light receptive. Light sensitivity is a complaint from the patient, and only brief phrases are spoken.
The clinical indications indicate the existence of aspiration pneumonia, which occurs when anything other than air accidentally enters the lungs. It might be a liquid, a solid meal, or any other foreign item (Tiwari et al., 2022). The clinical symptoms and treatment regimens for community-acquired pneumonia and aspiration pneumonia are similar, but the clinical courses are not (Lanks et al., 2019). Patients hospitalized with aspiration pneumonia have a more difficult prognosis, which typically needs additional therapies and care in an intensive care unit (ICU).
Escalation
Nursing care, particularly home care, is required for the patient to recover quickly and avoid infection recurrence. It is advised that the patient with pneumonia rests in a Fowler’s or high-posture Fowler’s at home and changes positions periodically (Makhnevich et al., 2019). Keeping the patient upright promotes lung expansion, while regular changes in posture and ambulation allow lung secretions to flow about. To begin, nursing care for the patient entails a combination of clinical, physical, and dietary measures. Fluid intake of 2500-3000 mL per day would aid in clearance since fluids assist in liquefying secretions (Grief & Loza, 2018). The nurse should help the patient deepen his or her breath, cough, and use supportive equipment. The actions assist in airway clearing.
In case the patient is intubated during this test, the practitioner should employ an aseptic approach to deliver endotracheal suctioning. The patient’s activity tolerance must be assessed on a frequent basis, with any changes in pulse, dyspnea, respirations, cyanosis, or diaphoresis noted (Neill & Dean, 2019). The results of these tests would indicate whether or not a person’s activity tolerance is hindered or limited. The caregiver should also check the patient’s pleuritic pain and prescribe analgesics as directed by the physiotherapist (Neill & Dean, 2019). Appropriate pain management improves optimal breathing and reduces the need for splinting.
Oxygen Management
As the doctor may provide orders, the caregiver should supply oxygen. Because it raises the concentration of alveolar oxygen, oxygen therapy is an important medical intervention and nursing care technique. It also creates a pathway for oxygen to permeate through the alveolar-capillary membrane, lowering anxiety and hypoxia (Kosutova & Mikolka, 2021). Monitor oxygen levels and titrate oxygen to maintain an oxygen saturation of greater than 92%. To restore the body’s compromised immune system, patients suffering from this disease generally require considerable bed rest and plenty of water. If the illness has severely harmed lung function, the doctor may prescribe oxygen therapy (Kosutova & Mikolka, 2021). Supplemental oxygen can help lungs that have been compromised by illness function properly again. Supplemental oxygen as therapy has the advantage of being simple to administer at home without the need for extra medical support.
Pharmacological Management
Pneumonia is a disease that is easier to prevent than treat. Getting a pneumococcal vaccine, quitting smoking, and strengthening one’s immune system can help avoid pneumonia. If a person contracts pneumonia, the therapy will be determined by the type of the disease. As potentially effective pharmacological interventions, antibiotics and supplementary corticosteroids are suggested. In the first case, pharmacological management implies prescribing drugs in accordance with microbiological tests, which can help identify the optimal dosage and possible contraindications (Peyrani et al., 2018). In the second case, supplementary corticosteroids should be prescribed through short courses of administration depending on the severity of the disease since, as Yang et al. (2020) note, these drugs are less effective at targeting CAP and are rather alternative than mainstream medications. Therefore, taking antibiotics is the preferred form of treatment for CAP.
Antibiotics are commonly used to treat bacterial pneumonia because they inhibit germs from growing. Antibiotics can be taken orally or administered intravenously by a doctor. Such antibiotics as Cipro, Levaquin, and Oracea are frequently administered (Grief & Loza, 2018). Antibiotics can cause diarrhea, nerve damage, and allergic reactions, among other things. To treat pneumonia symptoms, doctors may prescribe cough suppressants and fever reducers. Over-the-counter analgesic pain medications like ibuprofen and acetaminophen are available (Grief & Loza, 2018). Some cough treatments are available over-the-counter, but if the cough is severe, a cough suppressor, such as codeine, may be required. Antiviral (Zanamivir) and antifungal drugs may be used for viral pneumonia or pneumonia caused by a fungus (Grief & Loza, 2018). According to Dandachi and Rodriguez-Barradas (2018), the benefits of using antiviral drugs include suppressing the progress of the disease and addressing a specific type of pneumonia if it is a viral illness. Nonetheless, taking antibiotics is a more common form of therapeutic intervention.
Corticosteroid usage may hasten symptom remission and improve clinical stability. The review of 13 randomized controlled trials indicated that severe pneumonia mortality, the requirement for mechanical ventilation, the occurrence of acute respiratory distress syndrome, the time to clinical stabilization, and the length of hospitalization all dropped considerably (Mathur et al., 2018). Patients using corticosteroids had a higher rate of hyperglycemia that required treatment. There is no ideal agent or dosage due to the variability in dose and mode of delivery (Okafor et al., 2021). More study is needed to identify steroid dose and duration, as well as which patient demographics will benefit the most from its use.
Psychosocial Management
In addition, the caregiver should collaborate with the physiotherapist and doctor to offer appropriate pulmonary hygiene treatments such as percussion, vibration, and drainage. To reduce worry and tension, the caregiver should engage the aid of the patient’s relatives (Schwarz et al., 2018). High levels of worry and stress might reduce a patient’s exercise tolerance and raise metabolic needs. When there is extended bed rest, either passive or active range-of-motion (ROM) exercises are critical because they preserve joint mobility and muscle tone and lower the likelihood of contractures (Schwarz et al., 2018). Antibiotics, analgesics, and antipyretics provided by a qualified health care provider can successfully treat aspiration pneumonia. Depending on the patient’s risk factors, the patient’s reaction might range from 48 hours to seven days. Aerosol treatments, chest physiotherapy, and ABG analysis are all provided by respiratory therapists (Schwarz et al., 2018). Physical therapists assess if assistance aids and rehabilitative exercise are required. Nutritionists highlight the importance of a well-balanced diet for recovery.
Collaborative Management
The patient seems relaxed, polite, and cheerful, and the family is supportive. The patient is taught why they should use an incentive spirometer, how to use it, and how often they should use it. Additionally, they are instructed on the importance of deep breathing and correct coughing methods. The necessity of being active and ambulating with assistance or utilizing an assistive device is instilled in the patient. Furthermore, the patient should be informed about new drugs, including any potential adverse effects and drug or dietary interactions. It is critical to stress the necessity of finishing the antibiotic’s prescribed dose (Egleston, 2018). The nurse should further inform the patient that it will take many weeks for them to recuperate.
Covering the mouth while coughing or sneezing, hand washing, appropriate relaxation and exercise, and a correct diet are all good health habits to practice. The practitioner needs to discuss with the sick person how important it is to have a low-sodium diet (Egleston, 2018). The nurse should also consider explaining why it is important to stay hydrated. Teaching the patient about the need to be vaccinated against pneumococcal and influenza is also an important factor. For proper treatment and rehabilitation, the patient can be sent to a respiratory and physical therapist.
The patient must call their doctor if the signs and symptoms of pneumonia reappear, such as fever, chills, exhaustion, shortness of breath, cough, or chest discomfort. The nurse should inform the patient about atypical pneumonia symptoms such as pain, weariness, mobility limitation, falls, or difficulty thinking or reasoning. Reminding the patient to stay hydrated throughout the day by having water nearby and sipping is also essential. Teaching how to read labels to determine how much salt is in their meals is further advised. Covering the mouth, frequent hand washing, appropriate relaxation and exercise, and a correct diet are all good health habits to practice.
References
Blomberg, B., & Sharda, N. (2022). Aspiration pneumonia. Pathy’s Principles and Practice of Geriatric Medicine, 1, 522-529.
Chan, A., Bassetti, J., & Feuille, E. (2018). A case of recurrent aspiration and pneumonia and persistent eosinophilia. Annals of Allergy, Asthma & Immunology, 121(5), S95.
Dandachi, D., & Rodriguez-Barradas, M. C. (2018). Viral pneumonia: Etiologies and treatment. Journal of Investigative Medicine, 66(6), 957-965.
Egleston, S. (2018). The forgotten complication: Aspiration pneumonia in the canine patient. The Veterinary Nurse, 9(3), 138-143.
Grief, S. N., & Loza, J. K. (2018). Guidelines for the evaluation and treatment of pneumonia. Primary Care: Clinics in Office Practice, 45(3), 485-503.
Gunay, L., Yesılbag, Z., Gedık, H., Karabela, Ş. N., Engin, G., Gunaydın, N., & Yasar, K. K. (2018). Ventilator associated pneumonia prevention experience in cardiovascular surgical intensive care. American Journal of Cardiology, 121(8), e158-e159.
Kosutova, P., & Mikolka, P. (2021). Aspiration syndromes and associated lung injury: Incidence, pathophysiology and management. Physiological Research, 70, S567-S583.
Lanks, C. W., Musani, A. I., & Hsia, D. W. (2019). Community-acquired pneumonia and hospital-acquired pneumonia. Medical Clinics, 103(3), 487-501.
Lee, A. S., & Ryu, J. H. (2018). Aspiration pneumonia and related syndromes. Mayo Clinic Proceedings, 93(6), 752-762.
Maeda, K., Murotani, K., Kamoshita, S., Horikoshi, Y., & Kuroda, A. (2021). Nutritional management in inpatients with aspiration pneumonia: A cohort medical claims database study. Archives of Gerontology and Geriatrics, 95, 104398.
Makhnevich, A., Feldhamer, K. H., Kast, C. L., & Sinvani, L. (2019). Aspiration pneumonia in older adults. Journal of Hospital Medicine, 14(7), 429-435.
Mathur, S., Fuchs, A., Bielicki, J., Van Den Anker, J., & Sharland, M. (2018). Antibiotic use for community-acquired pneumonia in neonates and children: WHO evidence review. Paediatrics and International Child Health, 38(sup1), S66-S75.
Neill, S., & Dean, N. (2019). Aspiration pneumonia and pneumonitis: A spectrum of infectious/noninfectious diseases affecting the lung. Current Opinion in Infectious Diseases, 32(2), 152-157.
Okafor, C. E., Ekwunife, O. I., & Nduaguba, S. O. (2021). Promoting the integrated community case management of pneumonia in children under 5 years in Nigeria through the proprietary and patent medicine vendors: A cost-effectiveness analysis. Cost Effectiveness and Resource Allocation, 19(1), 1-10.
Peyrani, P., Mandell, L., Torres, A., & Tillotson, G. S. (2018). The burden of community-acquired bacterial pneumonia in the era of antibiotic resistance. Expert Review of Respiratory Medicine, 13(2), 139-152.
Schwarz, M., Coccetti, A., Murdoch, A., & Cardell, E. (2018). The impact of aspiration pneumonia and nasogastric feeding on clinical outcomes in stroke patients: A retrospective cohort study. Journal of Clinical Nursing, 27(1-2), e235-e241.
Tiwari, D., Kitchener, R., Richards-Taylor, S., Whiffen, M., & Allen, S. (2022). Improving mortality outcomes in aspiration pneumonia: Training, technology and teamwork. BMJ Open Quality, 11(1), e001553.
Yang, J. W., Yang, L., Luo, R. G., & Xu, J. F. (2020). Corticosteroid administration for viral pneumonia: COVID-19 and beyond. Clinical Microbiology and Infection, 26(9), 1171-1177.