Nursing Management of Patient with Community Acquired Pneumonia F.P.

, a 78 year old female with a medical history of Asthma, was diagnosed with Community Acquired Pneumonia – Moderate Risk. One month prior to admission, patient experienced productive cough, whitish in color, associated with headache, both temporal non-radiating, punching, shortness of breath and asthma attack, body malaise and easy fatigability with loss of appetite. Ignatavicius and Workman (2006) has stated that older patients diagnosed with Pneumonia often has weakness, fatigue, lethargy, confusion, and poor appetite. Fever and cough maybe absent. Due to ineffective airway clearance related to effects of infection, excessive tracheobronchial secretions, fatigue and decrease energy, chest discomfort, and muscle weakness, some interventions are expected to maintain patent airway. Pathophysiology Pneumonia is an inflammation or infection of the lungs most commonly caused by a bacteria or virus. Hockenberry and Wilson (2007) has explained that pneumonia can also be caused by inhaling vomit or other foreign substances. Ignatavicius and Workman (2006) claimed that in all cases, the lungs' air sacs fill with pus, mucous, and other liquids and cannot function properly. This means oxygen cannot reach the blood and the cells of the body. According to Hockenberry and Wilson (2007), most pneumonias are caused by bacterial infections. The most common infectious cause of pneumonia in the United States is the bacteria Streptococcus pneumoniae. Bacterial pneumonia can attack anyone. The most common cause of bacterial pneumonia in adults is a bacteria called Streptococcus pneumoniae or Pneumococcus. Pneumococcal pneumonia occurs only in the lobar form. Hockenberry and Wilson (2007) also stated that an increasing number of viruses are being identified as the cause of respiratory infection. Half of all pneumonias are believed to be of viral origin. Most viral pneumonias are patchy and the body usually fights them off without help from medications or other treatments. Pneumococcus can affect more than the lungs. The bacteria can also cause serious infections of the covering of the brain (meningitis), the bloodstream, and other parts of the body. According to Ignatavicius and Workman (2006), communityacquired pneumonia develops in people with limited or no contact with medical institutions or settings.

The most commonly identified pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms (ie, Chlamydia pneumoniae,Mycoplasma pneumoniae, Legionella sp) (Pillitteri, 2010). Signs and symptoms are fever, cough, pleuritic chest pain, dyspnea, tachypnea, and tachycardia. Diagnosis is based on clinical presentation and chest x-ray. Treatment is with empirically chosen antibiotics. Prognosis is excellent for relatively young or healthy patients, but many pneumonias, especially when caused by S. pneumoniae or influenza virus, are fatal in older, sicker patients (Ignatavicius and Workman, 2006). History F.P., a 78 year old female with a medical history of Asthma and Rhematoid Athritis, was diagnosed with Community Acquired Pneumonia - MR. One month prior to admission, patient experienced productive cough, whitish in color, associated with headache, both temporal and radiating, punching, shortness of breath and asthma attack, body malaise and easy fatigability with loss of appetite, joint and muscle pain (upper and lower extremities). Not associated with fever, abdominal pain, nausea and vomiting. Patient self medicated with Biogesic 500mg/tab PRN for headache, Salbuthamol neb for asthma attack. Patient had a cataract operation. The physician prescribed the patient Lagundi leaves but no relief. Few hours prior to admission, patient still with the above signs and symptoms, which prompted the patient to consult at ER (Fatima University Medical Center) and subsequently admitted.

Nursing Physical Assessment F.P. was awake, lying on bed, conscious and coherent with an ongoing IVF of D5LR at 900cc level regulated at 25 gtts/min, infusing well. The patient’s temperature was 37.4 C, pulse rate was 90, respirations were 24, blood pressure was 130/60. The patient’s skin is dry, soft, brown and no lesions present. The patients stated no bowel movement but had passed flatus. The urine output from 6am-12pm was 1200ml. The patient is on a low salt low fat diet. The patient was non-ambulatory and was not able to perform independent activities of daily living.

Related Treatment F.P. had undergone the following laboratory exams, complete blood count (CBC) is obtained to identify leukocytosis (an elevated white blood count). Urinalysis, urine is examined for blood, pus, or protein, which may occur in the septic patient with pneumonia. Arterial blood gases (ABGs) determine the baseline arterial oxygen and carbon dioxide levels and help identify a need for supplemental oxygen. Serum electrolyte, Blood urea nitrogen (BUN), and creatinine levels are also assessed. A high BUN level may occur as a result of dehydration. Patient’s sputum is obtained and examined by Gram stain, culture, and sensitivity testing. Chest X-ray is also performed for early diagnosis of pneumonia because symptoms are often vague (Ignatavicius and Workman, 2006). The patient has an ongoing IVF of D5LR at 900cc level regulated at 25 gtts/min as ordered by the physician, to prevent electrolyte imbalance. The physician also ordered for the patient to have a low salt, low fat diet. According to Cansino and Lipsett (2007), theraphy involves the use of an appropriate antibiotic. The patient’s medications ordered by the physician were, Eroxmit(Cefuroxime) – 750mg/IV: bactericidal, indicated for Upper respiratory tract infection. Aeknil(Paracetamol) 500mg/tab every 4 hours for fever as needed. Zithromax(Azithromycin) 500mg/tab: penicillin, indicated for upper and lower respiratory tract infection. Ectrin(Erdosteine) 300mg/cap twice a day: antitusive as an expectorant and mucolytic. Omeprazole 20g/tab: proton pump inhibitor as an antacid. Nursing Care Plan F.P.’s nursing diagnosis is Ineffective airway clearance related to excessive tracheobronchial secretion. She has ineffective cough with excessive sputum. She also manifests wheezing breath sounds. The short term goal is to expect the patient to maintain a patent airway, indicated by, effective cough and absence of wheezes on auscultation. According to Ignatavicius and Workman (2006) the nursing intervention for the patient with pneumonia for ineffective airway clearance are similar to those with COPD or asthma. Because of fatigue, muscle weakness, chest discomfort, and excessive secretions, the patient with pneumonia often has difficulty clearing secretions. To maintain adequate, patent airway; respirations and breath sounds

should be monitored, rate and sounds should also be noted for indication of respiratory distress and/or accumulation of secretions, head should be positioned appropriately for condition to open or maintain open airway in at-rest (Doenges, 2008). To mobilize secretions; deep-breathing and coughing exercises should be encouraged to maximize effort, medications prescribed by the physician should be duly given (Doenges, 2008). Ignatavicius and Workman (2006) pointed that dehydration should be avoided, adequate hydration may help to thin secretions and make them easier to remove. To assess changes and note complications; breath sounds should be auscultated and air movement should be assessed to ascertain status and note progress, signs of respiratory distress should also be observed, chest x-rays/ABGs/pulse oximetry readings should be monitored/documented (Doenges, 2008). To promote wellness; client’s knowledge of contributing causes, treatment plan, specific medications, and therapeutic procedures should be assessed, opportunities for rest should be provided, activities should be limited to level of respiratory tolerance (Doenges, 2008). The expected outcome to maintain patent airway for the patient has been met. Recommedations F.P. should continue the medications prescribed by the physician. The patient should also be instructed to notify the health care provider if chills, fever, persistent cough, dyspnea, wheezing, hemoptysis, increased sputum production, chest discomfort, or increase fatigue recurs or if symptoms fail to resolve. Ignatavicius and Workman (2006) has pointed to emphasize the importance of getting plenty of rest and gradually increasing exercise. The patient should be instructed to avoid crowds, people who have a cold or flu, and exposure to irritants such as smoke. Ignatavicius and Workman (2006) has claimed that balance diet and adequate fluid intake are essential. The patient should also be informed that smoking is a risk factor for pneumonia.

Nursing Management of Patient with Community Acquired Pneumonia Suzaine Marie F. Suarez Our Lady of Fatima University

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