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Mr. N. pneumonia case: A case study

In the following pages the case study of Mr. N will be presented with a diagnosis of pneumonia. Pneumonia is an infection of the lower respiratory tract. It can be caused by viral, bacterial, fungal, protozoa, or parasitic infections (Brashers, 2006). Pneumonia may be acquired by the community, known as community acquired (CAP). It can be acquired in a nursing home (NHAP). Pneumonia can also be contracted in the hospital and this type of pneumonia is known as a nosocomial infection. Mr. N was diagnosed with right upper lobe pneumonia for initial diagnosis.

Mr. N is a young, Caucasian, Christian, upper-middle class man 36 years of age. The patient is a non-smoker. He is married with 2 children and expecting a third child. He presented to the hospital complaining of acute onset of fever, chills, rigors, pleuritic chest pain, cough, and excessive vomiting. This man was writhing in pain, heaving, and vomiting excessively. Our main goal was getting him comfortable to aid in caring for him after receiving him from the ER in the MICU. He had been at a doctor’s appointment prior to admission and sent over by his endocrinologist. Ordered lab tests of a CMP, CBC, Blood Cultures X 2; and a urinalysis were obtained and sent to lab for processing. A Chest x-ray was obtained by radiology in the emergency department. Mr. N was placed on a dilaudid pain pump for excessive complaints of pain and chronic pain history. Oxygen at 2L per nasal canula was placed on the patient. Breathing treatments were initiated for every 4 hours. Mr. N was encouraged to use his incentive spirometer 10 times every 2 hours. He was encouraged to wear his SCD’s for circulation and to turn, cough, and deep breathe frequently. The patient was placed on NPO status due to excessive vomiting. His previous TPN order was resumed along with an IV of normal saline at 100 cc/hour. Patient was instructed to keep head of bead at 30 degrees or greater.

He has previous history of Lupus, Sjogren’s disorder, diabetes, malnutrition, gastroparesis with chronic vomiting, recurrent infections, primarily pneumonia. The patient had been in the hospital with aspiration pneumonia three weeks prior to this admission. This young man had multiple admissions and treatments. He had spent 164 days in the hospital a few years prior to this hospitalization. Most of the hospitalizations consisted of acute pancreatitis and chronic pancreatitis issues that were thought to be a secondary problem to Lupus. He had been to Mexico and Russia for stem cell treatments to help with chronic inflammation secondary to Lupus and Sjogren’s under the encouragement of Dr. Bayer who is a huge supporter in Stemedica. Stemedica Cell technologies, inc., are thought to be transforming regenerative medicine through the development and manufacturing of adult ischemic-tolerant stem cell products and biological (Stemedica Cell Technologies, 2007-2014, p. 1).

Mr. N had undergone pancreatic biopsies in Illinois in attempt to find the cause of all his illnesses. This biopsy sent him into his first acute pancreatitis episode and his health had never been the same. He had undergone two abdominal surgeries prior to admission. The first was a duodenojejunostomy in attempt to tube feed him due to significant weight loss from the gastroparesis. At the time of this surgery, the patient was diagnosed with SMA syndrome. SMA syndrome is also known as superior mesenteric artery syndrome. SMA is a rare acquired disorder in which acute angulations of the SMA causes compression of the third part of the duodenum between the SMA and the aorta, leading to obstruction (Archana, Gisel, & Bouras, 2005, p. 1). His gastroparesis was also thought to have stemmed from Lupus and diabetes. His second surgery was performed by Dr. Langley the previous winter. The patient stated the surgeon didn’t have a name for this surgery. It also was an attempt to alleviate vomiting and to promote gastric motility from the stomach to the bowel differently. Since that surgery, the patient’s mother had passed away unexpectedly, and his vomiting was not been relieved by surgery. In fact, it was worsening. He had a right subclavian central line port in place due to receiving TPN at home.

His medications include; prednisone 5 mg by mouth once daily, zofran 4 mg by mouth every 6-8 hours for nausea; Plaquinil 400 mg once by mouth twice daily; Hydrocodone 5-10 mg every 4-6 hours for pain; Salogen 5mg by mouth four times per day; Lyrica 600 mg one by mouth two-three times per day; Creon 500 lipase units/kg by mouth with meals/snacks, Humalog insulin pump, Dexilant 60 mg once per day, and Topamax 200 mg by mouth twice per day. Mr. N’s vital signs were obtained. He had a blood pressure of 200/90, a pulse of 148 beats per minute; a respiratory rate of 32 breaths per minute, and a pulse oximetry on room air was 88%. His temperature is 102 degrees Fahrenheit.

Mr. N was awake, alert, and oriented to person, place, and time. His pupils were at 3mm equal, accommodated, and reactive to light. S1 and S2 heart tones were audible with no murmur, or extra heart tones noted. The patient’s lungs were diminished throughout all lung fields with scattered rales. The right upper lobe of lung greater diminishing was noted. Bowel sounds were hypoactive in all four quadrants. The abdomen was soft, nondistended, and tender upon palpation. All peripheral pulses were palpable at 2+. Generalized edema noted. His right subclavian central line site dressing was clean, dry, and intact. The insertion site was with mild redness but no warmth was noted. The patient was not ambulatory at this time due to pain, vomiting, and malaise.

Lab results revealed a potassium of 3.2. White blood cell count was 19.0. A left shift of leukocytes was noted. Hemoglobin was 7.8 and hematocrit was 28.7. Urinalysis was normal. The chest x-ray revealed patchy infiltrates throughout with greater consolidation noted to right upper lobe. The next morning blood cultures were positive for yeast.

Host defenses to lung infections are influenced by genetic components of inflammation that are inherited, and our body’s ability to fight disease, and pulmonary-precise defense processes (Brashers, 2006). In acquiring bacterial pneumonia, the organism is often aspirated, inhaled or spread in the blood stream from other sites of infection. The upper airway is essential in resisting infections. The ability for saliva, cough, gag reflex, and the antibody in the mucosa IgA can be repressed by diseases, smoking, poor immunity, and endotracheal intubation.

The lower airway has cilia in the mucous membranes that attempt to force contaminants out of the lungs. Surfactants coat the alveoli and reduce tension; keeping the alveoli from collapsing. This allows the oxygen to penetrate the lung lining and move into the blood. Macrophages are important cells of the immune system that are created in response to an infection or accumulating damaged or dead cells. Macrophages and leukocyte phagocytosis is another response to the lower respiratory tract to fight infection. Macrophages and leukocytes engulf the opposing ill causing agent. Cell mediated immunity is the activation of lymphocytes and the destroying of intracellular microbes (Kumar, Abbas, Fausto, & Aster, 2010). Humoral immunity is the activation of B cell lymphocytes and eliminates extracellular germs (Kumar et al., 2010). Cellular and humoral immunity are both defenses of offending agents in the lower respiratory tract. Some of these defense mechanisms might be altered by decreased consciousness, smoking, cystic fibrosis, chronic bronchitis, immunocompromise, intubation, or lengthy bed rest (Brashers, 2006).

Dust cells or monocytes in the lungs live on the surfaces in the lungs and clean off particles such as dust or microorganisms. They are a primary defense system against invasion of the lower respiratory tract. Every day, dust cells clear the airways of offending organisms without creating a large inflammatory response. If the bacteria is too great and capable of causing disease by breaking down the protective mechanisms of the host, the macrophage with recruit leukocytes, and spark the inflammatory response by releasing cytokines. Cytokines are proteins released by the immune cells and act on other cells to coordinate appropriate immune responses. This response leads to inflammation.

The inflammation causes ventilation-perfusion mismatch and results in hypoxemia. Apoptosis of the lung cells occurs with hypoxemia. Apoptosis is the process of programmed cell death in the body. This action helps destroy any offending agent such as bacteria, tuberculosis, influenza, of fungal infections in the lungs. The action of apoptosis is beneficial in fighting infections, but it also plays a role in lung damage. The infection can remain in the lungs or it may result in septicemia, meningitis, endocarditis, and/or systemic inflammatory response syndrome (SIRS) (Brashers, 2006).

Lupus is an autoimmune disease. This mean’s the body’s natural defense system, immune system, attacks healthy tissues instead of attacking only bacteria and viruses. This causes inflammation. Lupus affects the lungs, muscles, brain, heart, and kidneys. Sjogren’s syndrome is an autoimmune disorder where the glands that produce tears and saliva are destroyed. The condition may affect other parts of the body, including kidneys, lungs, and pancreas. Insulin-dependent diabetes mellitus, now known as diabetes mellitus type 1, is an autoimmune disease known resulting in the destruction of insulin-producing cells. This young man’s overactive immune system attacked his pancreas resulting in diabetes. Chronic inflammation causes infection. His body is chronically inflamed by his over reactive immune system. He has a damaged immune response. Since Sjogren’s can in fact affect his lungs; the surfactants in his lungs may be less; therefore decreasing the oxygenation. High glucose levels are caused by hormones produced to combat illnesses. Stress and illness trigger high blood sugar. Mr. N’s body is chronically stressed, and managing his blood sugar was difficult.

After, receiving a positive blood culture of yeast; the central line was discontinued and sent for culture. The patient continued to experience low oxygen levels and began to have an altered level of consciousness. He was sent for a cat scan of the lungs and it revealed right upper lobe pneumonia and embolic pneumonia of the left upper and lower lobes. The central line was positive for yeast. A picc line was placed for IV access.

Antifungals were added to the current broad spectrum IV antibiotics to fight the bacterial and fungal infections. Reduced mortality is found with quick initiation of antibiotic treatment. Corticosteroid therapy was initiated through his IV to combat his inflammatory response. Steroid therapy and antibiotic therapy improve gas exchange and patient outcomes. An insulin drip with every hour glucose checks was started for blood sugar regulation. This would facilitate healing and fighting the infections. Potassium bolus was initiated and given every six hours for K level of 3.2 to prevent arrhythmias. After his vomiting had decreased, the patient was able to have a clear liquid diet. Lovenox injections were started for prevention of DVT. The patients breathing treatments, incentive spirometry, and turn, cough, and deep breathing techniques were strongly encouraged.

There are several nursing diagnosis that need to be addressed with a diagnosis of pneumonia; including the patient deficit knowledge, risk for dehydration, unbalanced nutrition, acute pain, activity intolerance, risk for infection, impaired gas exchange, and last but not least, ineffective airway clearance. Airway management always needs to be addressed initially. Ineffective airway clearance is the first nursing diagnosis that would need to be addressed in Mr. N’s hospitalization. The airway, when pneumonia is present could be compromised due to the presence of secretions. The breathing pattern would be affected. The alteration in the patient’s oxygen and carbon dioxide ratio due to decreased oxygen and poor gas exchange due to exudates on the alveoli causes increase in respiratory rate. Hyperventilation begins to cause an increase in the tidal volume of air to facilitate absorbing more oxygen. Bronchospasms occur and may cause dyspnea, nonmoving secretions, and infection. There are several attempts by the nurse to create effective breathing. Mr. N and his family were taught on the importance of wearing his oxygen and to cooperate with ordered breathing treatments. This would boost his oxygen absorption and increase healing efforts. On admission, the patient was encouraged to CDB with frequent position changes, to keep head of bed at 30 degrees or higher, and to use his incentive spirometer every two hours as ordered. The patient was instructed to compliance with respiratory therapy. The patient has a history of aspiration and continued to experience vomiting, putting him at higher risk for aspiration again. All of these interventions will aid in airway exchange. The family and patient were taught on the importance of all of these techniques to assist the patient’s wellness.

If antibiotics are initiated within the first four hours of hospitalization, chances of death are significantly reduced. This patient’s labs show significant decrease in hemoglobin and a major left shift in leukocytes increases the opportunity for bacteria to invade and set up camp in a specific body part. In this case, the patient’s initial infection was right upper lobe pneumonia. Embolic pneumonia was the second diagnosis. The central line was removed due to the cultured tip revealing growth of yeast. The yeast from the catheter showered infected emboli to the lungs. Infection is a top priority in this case. Antifungal IV therapy increased his chances of survival along with antibiotic administration. Good universal precautions are a must with this patient. His immune system is constantly compromised and good hand washing with him, the staff, and family would be supportive of his overall health. A dietician was consulted to increase nutrition due to vomiting, and history of malnutrition. Proper TPN administration and nutritional intake serves a huge purpose in infection control.

Pain and nausea control would be significant in maintaining affective breathing, appropriate gas exchange, and resolving infection. The patient’s admitting physician continued home medications upon admission. Dilaudid was ordered for adequate pain control. P.O. zofran was changed to IV route. The nursing staff reported to the medical team that zofran was not relieving his nausea. IV phenergan was attempted without results. IV Compazine was ordered and nausea control was achieved. Pain and nausea contributed to inadequate breathing and gas exchange. The risk of aspiration due to vomiting increases infection risk. Mr. N’s medical team, nursing staff, dietician, and family worked assertively in resolving pain and nausea by appropriately communicating with one another.

Expected out comes for Mr. N and maintaining his airway was achieved by physician orders, nursing and respiratory staff initiating, administering, and following up with ordered medications and treatments. Continuous teaching to the patient, family, and among each other created a very positive outcome for Mr. N. Difficulty of breathing was relieved and airway was maintained throughout his hospitalization. The patient was able to verbalize understanding and demonstrate deep breathing techniques. This intervention encouraged by all involved staff helped achieve proper oxygenation and to alleviate hyperventilation. The patient remained free of cyanosis and was able to establish a normal breathing pattern. With all medications, interventions, and the patient’s ability to remain compliant, the ease of breathing was achieved. Ordered pain, nausea, and respiratory medications and treatments carried out by all were successful in maintaining adequate airway; good gas exchange, and effective breathing. Mr. N’s wife was able to intervene with noticing decreased level of consciousness in the patient and bi-pap was ordered for one day of his hospitalization. This helped the patient when he was compromised and facilitated adequate gas-exchange. He was able to return to a nasal canula the next day and necessary airway was maintained.

The patient’s wife was able to help encourage the patient to use appropriate hand washing, sanitizing, and assist in overall cleanliness to prevent spread of infection. She, the patient, the staff strongly encouraged visitors to adhere to precautions as well. Adherence and timeliness in administering prescribed antibiotics and antifungals was necessary and achieved by the nursing staff during Mr. N’s hospitalization. Housekeeping did an excellent job in maintaining a clean environment. Proper disinfectants used during cleaning, facilitated the spread of infection as well.

The multidisciplinary treatment plan was very effective due to proper communication and adherence to the plan of treatment by the patient and family. Mr. N’s knowledge of his diseases was a positive factor in acceptance of encouraged treatments and interventions. The medical team consisted of the hospitalists, pulmonologist, endocrinology, and infectious disease. The team was above average in collaborative care. There collaboration cascaded to the nursing staff, dietary consults, and respiratory therapy.

The hospitalist established a rapport with the patient. This was a huge bonus in the patient’s emotional and physical healing. The rapport with the doctors and the patient facilitated the trust and relationship with the nursing and all ancillary departments. This is extremely important in overall healing for the patient and family. All of the team working together and the patient and family compliance was a strong force in pulling this patient through and resulted in him living. Trust between the patient, medical staff, nursing staff, and all ancillary departments was necessary in the patient’s ability to heal properly.

Trust developed during Mr. N’s hospitalization between his medical team and nursing staff allowed him to share that he believed to be overmedicated and had a history of abusing pain medications in attempt to cope with his ongoing disease processes. The physicians were then able to treat the patient appropriately and were successful in discontinuing all ordered medications before dismissal without significant withdrawal problems. The patient was dismissed with only ordered antibiotics and antifungal therapy. Scheduled follow-up appointments with the physician’s encouraged adherence to the continued plan of treatment and would hopefully prevent early readmission. Allowing the patient to play a role in his treatment as an expert to his ongoing illnesses was big in establishing a relationship and executing appropriate care.

Trust is still fundamental to any clinician-patient relationship (European Journal of Public Health, 2006). There is a shift for more informed patients to participate in decision-making. The role of trust in this specific scenario was extremely beneficial in the achieved outcome.

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