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Nursing Crib Case Study Pneumonia Physical Assessment

Betty was admitted at the community hospital for a week because of acute gastroenteritis and was discharged last Monday. On Thursday, her mother noticed that her 9-year old is breathing faster than she normally does. She is also very warm to touch and is complaining of chest pain. On Saturday, she began spitting out greenish sputum.

Contents

Description


Respiratory diseases are rampant today because it is easier spread in crowded areas. Pneumonia is one of the most common respiratory problems and it affects all stages of life.

  • Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi, and viruses.
  • Pneumonitis is a more general term that describes the inflammatory process in the lung tissue that may predispose and place the patient at risk for microbial invasion.

Classification


Pneumonia is classified into four: community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP), pneumonia in the immunocompromised host, and aspirationpneumonia.

  • CAP occurs either in the community setting or within the first 48 hours after hospitalization.
  • The causative agents for CAP that needs hospitalization include streptococcuspneumoniae, H. influenza, Legionella, and Pseudomonas aeruginosa.
  • Only in 50% of the cases does the specific etiologic agent become identified.
  • Pneumonia is the most common cause of CAP in people younger than 60 years of age.
  • Viruses are the most common cause of pneumonia in infants and children.

Hospital-Acquired Pneumonia

  • HAP is also called nosocomial pneumonia and is defined as the onset of pneumonia symptoms more than 48 hours after admission in patients with no evidence of infection at the time of admission.
  • HAP is the most lethal nosocomial infection and the leading cause of death in patients with such infections.
  • Common microorganisms that are responsible for HAP include Enterobacter species, Escherichia coli, influenza, Klebsiella species, Proteus, Serratia marcescens, S. aureus, and S. pneumonia.
  • The usual presentation of HAP is a new pulmonary infiltrate on chest x-ray combined with evidence of infection.

Pneumonia in the Immunocompromised Host

  • Pneumonia in immunocompromised hosts includes Pneumocystis pneumonia, fungal pneumonias and Mycobacterium tuberculosis.
  • Patients who are immunocompromised commonly develop pneumonia from organisms of low virulence.
  • Pneumonia in immunocompromised hosts may be caused by the organisms also observe in HAP and CAP.

Aspiration Pneumonia

  • Aspiration pneumonia refers to the pulmonary consequences resulting from entry of endogenous or exogenous substances into the lower airway.
  • The most common form of aspiration pneumonia is a bacterial infection from aspiration of bacteria that normally reside in the upper airways.
  • Aspiration pneumonia may occur in the community or hospital setting.
  • Common pathogens are S. pneumonia, H.influenza, and S. aureus.

Pathophysiology


Having an idea about the disease process helps the patient understand the treatment regimen and its importance, increasing patient compliance.

  • Pneumonia arises from normal flora present in patients whose resistance has been altered or from aspiration of flora present in the oropharynx.
  • An inflammatory reaction may occur in the alveoli, producing exudates that interfere with the diffusion of oxygen and carbon dioxide.
  • White blood cells also migrate into the alveoli and fill the normally air-filled spaces.
  • Due to secretions and mucosal edema, there are areas of the lung that are not adequately ventilated and cause partial occlusion of the alveoli or bronchi.
  • Hypoventilation may follow, causing ventilation-perfusion mismatch.
  • Venous blood entering the pulmonary circulation passes through the under ventilated areas and travels to the left side of the heart deoxygenated.
  • The mixing of oxygenated and poorly oxygenated blood can result to arterial hypoxemia.

Epidemiology


Pneumonia has affected a lot of people, especially those who have a weak immune system. Learning statistics on pneumonia could give you an idea about how many has fallen victim to this respiratory disease.

  • Pneumonia and influenza account for nearly 60,000 deaths annually.
  • Pneumonia also ranks as the eighth leading cause of death in the United States.
  • It is estimated that more than 915, 000 episodes of CAP occur in adults 65 years old and above in the United States.
  • HAP accounts for 15% of hospital-acquired infections and is the leading cause of death in patients with such infections.
  • The estimated incidence of HAP 4 to 7 episodes per 1000 hospitalizations.

Causes


Each type of pneumonia is caused by different and several factors.

Community-Acquired Pneumonia

  • Streptococcus pneumoniae. This is the leading cause of CAP in people younger than 60 years of age without comorbidity and in those 60 years and older with comorbidity.
  • Haemophilus influenzae.  This causes a type of CAP that frequently affects elderly people and those with comorbid illnesses.
  • Mycoplasma pneumoniae. 

Hospital-Acquired Pneumonia

  • Staphylococcus aureus. Staphylococcus pneumonia occurs through inhalation of the organism.
  • Impaired host defenses. When the defenses of the body are down, several pathogens may invade the body.
  • Comorbid conditions. There are several conditions that lower the immune system, causing bacteria to pool in the lungs and eventually result in pneumonia.
  • Supinepositioning. When the patient stays in a prolonged supine position, fluid in the lungs pools down and stays stagnant, making it a breeding place for bacteria.
  • Prolonged hospitalization. The risk for hospital infections or nosocomial infections increases the longer the patient stays in the hospital.

Clinical Manifestations


Pneumonia varies in its signs and symptoms depending on its type but it is not impossible to diagnose a specific pneumonia through its clinical manifestations.

  • Rapidly rising fever. Since there is inflammation of the lung parenchyma, fever develops as part of the signs of an infection.
  • Pleuritic chest pain. Deep breathing and coughing aggravate the pain in the chest.
  • Rapid and bounding pulse. A rapid heartbeat occurs because the body compensates for the low concentration of oxygen in the body.
  • Tachypnea. There is fast breathing because the body tries to compensate for the low oxygen concentration in the body.
  • Purulent sputum. The sputum becomes purulent because of the infection in the lung parenchyma which produced sputum-filled with pus.

Prevention


It is better to prevent the occurrence of pneumonia instead of treating the disease itself. Here are several ways that can help prevent pneumonia.

  • Pneumococcal vaccine. This vaccine can prevent pneumonia in healthy patients with an efficiency of 65% to 85%.
  • Staff education. To help prevent HAP, the CDC (2004) encouraged staff education and involvement in infection prevention.
  • Infection and microbiologic surveillance. It is important to carefully observe the infection so that there could be an appropriate application of prevention techniques.
  • Modifying host risk for infection. The infection should never be allowed to descend on any host, so the risk must be decreased before it can affect one.

Complications


Pneumonia has several complications if left untreated or the interventions are inappropriate. These are the following complications that may develop in patients with pneumonia.

  • Shock and respiratory failure. These complications are encountered chiefly in patients who have received no specific treatment and inadequate or delayed treatment.
  • Pleural effusion. In pleural effusion, the fluid is sent to the laboratory for analysis, and there are three stages: uncomplicated, complicated, and thoracic empyema.

Assessment and Diagnostic Findings


Assessment and diagnosis of pneumonia must be accurate since there are a lot of respiratory problems that have similar manifestations. The following are assessments and diagnostic tests that could determine pneumonia.

  • History taking. The diagnosis of pneumonia is made through history taking, particularly a recent respiratory tract infection.
  • Physical examination. Mainly, the number of breaths per minute and breath sounds is assessed during physical examination.
  • Chest x-ray. Identifies structural distribution (e.g., lobar, bronchial); may also reveal multiple abscesses/infiltrates, empyema (staphylococcus); scattered or localized infiltration (bacterial); or diffuse/extensive nodular infiltrates (more often viral). In mycoplasmal pneumonia, chest x-ray may be clear.
  • Fiberoptic bronchoscopy. May be both diagnostic (qualitative cultures) and therapeutic (re-expansion of lung segment).
  • ABGs/pulse oximetry. Abnormalities may be present, depending on extent of lung involvement and underlying lung disease.
  • Gram stain/cultures. Sputum collection; needle aspiration of empyema, pleural, and transtracheal or transthoracic fluids; lung biopsies and blood cultures may be done to recover causative organism. More than one type of organism may be present; common bacteria include Diplococcus pneumoniae, Staphylococcus aureus, a-hemolytic streptococcus, Haemophilus influenzae; cytomegalovirus (CMV). Note: Sputum cultures may not identify all offending organisms. Blood cultures may show transient bacteremia.
  • CBC. Leukocytosis usually present, although a low white blood cell (WBC) count may be present in viral infection, immunosuppressed conditions such as AIDS, and overwhelming bacterial pneumonia. Erythrocyte sedimentation rate (ESR) is elevated.
  • Serologic studies, e.g., viral or Legionella titers, cold agglutinins. Assist in differential diagnosis of specific organism.
  • Pulmonary function studies. Volumes may be decreased (congestion and alveolar collapse); airway pressure may be increased and compliance decreased. Shunting is present (hypoxemia).
  • Electrolytes.Sodium and chloride levels may be low.
  • Bilirubin. May be increased.
 

I.PATIENT ASSESSMENT DATA BASEA.GENERAL DATA 

1.Patient’s Name: K. I.2.Address: Sison, Pangasinan3.Age: 1 y/o & 1 mo.4.Sex: Female5.Birth Date: July 18, 20086.Rank in the Family: 1

st

child7.Nationality: Filipino8.Civil Status: Single (child)9.Date of Admission: August 30, 200910.Order of Admission:> Please admit order re service of Dr. Callanta> secure consent> I & O every shift & record> Monitor VS q 4° & record> DAT with SAP> Dx with CBC, CXR> IVF D

5

0.3 NaCl 500cc X 37-38 ugtts/min> Cefuroxime 250mg IVP q 8° ANST (-)> Pediatapp drops 1ml TID> Salbutamol + Ipratopium ½ neb q 6°> Paracetamol drops 100mg/ml 1ml q 4° prn for fever> E-zinc drops 1ml OD> refer accordingly11.Attending Physician: Dr. Callanta, MD

B.CHIEF COMPLAINT

Cough and difficulty of breathing for one week, feverfor three days prior to admission

C.HISTORY OF PRESENT ILLNESS

One week prior to admission, K. O. had positive signsand symptoms of cough and yellowish phlegm followed withfever, three days before admission. Her mother knowing thatthese signs and symptoms were just the usual cough that herdaughter had, she gave her carbocisteine drops for her coughand paracetamol drops for her fever. However, she noticed nochanges so she decided to bring her to Pozorrubio MunicipalHospital. She was diagnosed of Pneumonia and because of theseverity of the condition, she was admitted. She was giveninitial medications and has had her for further observationsand laboratory exams.