Case Study #2: Pneumonia

At Home
Day: 0
Time: 16h00
Place: At home
“Trixie stop barking,” Erin calls. She gets up from the couch slowly. “I can’t believe how tired I am.”
Taking a few steps towards the back door to let Trixie out, Erin stops at the corner of the kitchen island
and puts a hand out to steady herself on the counter.
“Oh my. Can’t catch. My breath. Trixie. Stop barking.”
Remembering it was her late husband who took care of the dog, her eyes tear up slightly.
“I miss him so,” she thinks.
Moving toward the back door, Erin reaches down and lifts Trixie up onto the washing machine to place
the leash on her.
“You stink, Trixie. Your bath will have to wait till I feel better. Not sure what is happening.”
Trixie, finally leashed, is lifted down and out they go through the back door into the cold winter air.
Erin gets down the steps and leans against the house to catch her breath. Meanwhile, Trixie relieves
herself against a flower pot.
After about a minute, Erin begins to walk very slowly, with Trixie pulling on the leash. After about five
minutes walking, Erin slows to a stop.
Looking back, Erin thinks to herself, “I have only walked about 50 meters. I am not sure I can even walk
back to the house.”
Erin takes out her cell phone and calls her son at work.
“Thomas, I don’t feel well. You need to come home.”
“Mom, I’m at work. What’s up?” Thomas asks.
“I can’t. Catch. My. Breath. I think. I need. To go. To the. Hospital.”
“I will be there in ten minutes Mom.”

Case Scenario Analysis

Learning Outcome
Given a 3.0 hours session, student nurses must be able to:
1. Know the health condition of the patient in the scenario.
 Summary of the Scenario:
The patient named Erin is a 74-year old female. She is widowed with four children, one of whom
lives at home and three lives separately. She describes herself as a non-smoker, but she smoked
socially when she was in her early twenties for about five years. She is a retired hairdresser. Erin
also has a small hairless Chihuahua named Trixie.
At home, she enjoys watching Netflix and playing “Solitaire and Scrabble with friends” on her
iPad. Erin tends to feel down when she thinks about her lower financial status and her advancing
age, and how she is becoming more forgetful and less energetic. She often feels alone but is
grateful to have the company of Trixie and the few friends she has left who are still alive. She
worries about falling and not being able to alert anyone to come to her rescue. Driving is
becoming hard for her, and she finds getting to the clinic and picking up her medications more
and more challenging, especially now that she doesn’t have her own doctor anymore and she
needs to go to the walk-in clinic.
When at 1600H at home, she feels tired and gets up from the couch slowly and suddenly can’t
catch her breath while taking care of the dog. After she felt better she leashed her dog and they
went through the back door into the cold winter air. It was her late husband who took care of the
dog.
After about a minute, Erin begins to walk very slowly. About five minutes walking, Erin slows to a
stop. She had only walked about 50 meters when she realized and was not sure she could even
walk back to the house. After that, she called her son immediately at work then told him she didn't
feel well and couldn't catch her breath. She needs to be admitted to a Hospital.
Health Condition of the Patient in the Scenario:
Based on the given scenario, the patient has Pneumonia. Pneumonia is a group of lung infections
that can be bacterial, viral, or fungal. People with pneumonia develop inflamed air sacs filled with
fluid. This makes breathing more difficult and may reduce oxygen levels in the blood, which can
be fatal. Both viral and bacterial pneumonia can spread to others through inhalation of airborne
droplets from a sneeze or cough. And can also get these types of pneumonia by coming into
contact with surfaces or objects that are contaminated with pneumonia-causing bacteria or
viruses. Fungal pneumonia can get from the environment.
The patient has Pneumonia due to her age and weak health condition which is vulnerable to
getting microorganisms causing the infection. Feeling tired, not feeling well, and unable to catch
her breath are some of the signs and symptoms of Pneumonia. In my assessment, she is
experiencing abnormal breath sounds, difficulty breathing, rapid shallow breathing, and sharp or
stabbing chest pain that gets worse when she breathes deeply. She also has an inability to
cough, low energy, and fatigue which is very common in patients with Pneumonia.

2. Prepare a nursing care plan for patient health needs.

Cues Nursing Nursing Objectives Nursing Rationale of the Evaluation

Diagnosis Interventions Nursing
Interventions
Subjective: Ineffective Short term goal: INDEPENDENT The goal was
“I feel tired, don’t airway After 3-4 hours of 1. Assess airway 1. Maintaining partially met.
feel well, and clearance r/t nursing interventions, for patency. patent airways is
cannot catch my copious the patient will always the first After 12 hours of
breath” as tracheobronchi demonstrate increased priority. nursing
stated by the al secretions as air exchange, classify 2. Auscultate lungs 2. This may interventions, the
patient. evidenced by methods to enhance for the presence indicate patient was able
abnormal secretion removal, and of normal or ineffective to demonstrate
Objective: breath sounds, identify to avoid specific adventitious airway air exchange,
● Abnormal difficulty factors that inhibit breath sounds. clearance. classify methods
breath breathing, effective airway 3. Assess to enhance
sounds: shallow clearance. respirations. 3. A change in the secretion
crackles breathing, and Note quality, usual respiration removal, know
● Difficulty inability to Long term goal: rate, pattern, may mean how to avoid
breathing cough. After 12 hours of depth, flaring respiratory specific factors
● Rapid, nursing interventions, of nostrils, compromise. that inhibit
shallow the patient will maintain dyspnea on effective airway
breathing, clear, open airways as exertion, clearance.
● Sharp or evidenced by normal evidence of
stabbing breath sounds, normal splinting, use of
chest pain rate and depth of accessory
that gets respirations, and ability muscles, and
worse when to effectively cough up position for
she breath secretions after breathing.
deeply. treatments and deep 4. Assess 4. Airway
● Low energy breaths. hydration status: clearance is
and fatigue skin turgor, impaired with
● Ineffective mucous poor hydration
cough membranes, and subsequent
tongue. secretion
thickening.
5. Patient teaching
5. Review patient’s will vary
understanding of depending on
disease process. the disease
condition as well
as the patient’s
cognitive level.
6. Teach the 6. The most
patient the convenient way
proper ways of to remove most
coughing and secretions is
breathing such coughing. So it
as taking a deep is necessary to
breath, holding assist the patient
for 2 seconds, during this
and coughing activity. Deep
two or three breathing, on the
times in other hand,
succession. promotes
oxygenation
before controlled
coughing.
7. The proper
sitting position
and splinting of
the abdomen
7. Educate the promote
patient in sitting effective
position, use of coughing by
pillow or hand increasing
splints when abdominal
coughing, use of pressure and
incentive upward
spirometer, the diaphragmatic
importance of movement.
ambulation, and Ambulation
frequent position promotes lung
changes. expansion,
mobilizes
secretions, and
lessens
atelectasis.
8. This position
promotes better
lung expansion
8. Position the and improved air
patient upright if exchange.
tolerated.
Regularly check
the patient’s
position to
prevent sliding 9. Fluids help
down in bed. minimize
9. Encourage the mucosal drying
patient to and maximize
increase fluid ciliary action to
intake to 3 liters move secretions.
per day
within the limits
of cardiac 10. Freshens
reserve and the mouth after
renal function. respiratory
10. Provide oral care secretions have
every 4 hours. been
expectorated.
11. The patient will
understand the
underlying
11. Educate patient principle and
on coughing, proper
deep breathing, techniques.
and splinting 12. This promotes
techniques. the safe and
12. Educate effective removal
patient/caregiver of secretions
 in suctioning from the airway.
techniques. Mod
ify techniques for
a home setting.
1. Increasing
DEPENDENT humidity of
1. Maintain inspired air will
humidified reduce thickness
oxygen as of secretions
prescribed by and aid their
physician. removal.
2. Promote
clearance of
airway
2. Give secretions and
medications as may reduce
prescribed, such airway
as antibiotics, resistance.
mucolytic
agents,
bronchodilators, 
expectorants,
noting
effectiveness
and side effects.

3. Prepare a drug study for the patient’s medications.

4. Identify the necessary assistive devices.

a. Incentive Spirometer Accessory
An incentive spirometer is a handheld device that promotes lung expansion. The device
keeps the lungs clear and helps patients breathe more deeply and fully. Not only do incentive
spirometers allow the lungs to remain active during recovery, but they can also help reduce
the risk of infections. Incentive spirometers ensure the lungs remain active. They encourage
deep breathing, lung expansion, and mucus clearance, which allows people to retrain their
lungs to take slower and fuller breaths and optimize ventilation.

b. Nebulizer
 - A nebulizer is a form of inhalation therapy, meaning you’re inhaling medication instead of
taking it orally or intravenously. For someone with a respiratory condition, inhalation
therapy is considerably more effective than the alternatives because the medication
reaches the affected area almost instantaneously. Healthcare providers may also
prescribe an inhaler or a nebulizer treatment to help loosen the mucus in the lungs and
help you breathe better. The most common medication for this is Ventolin, ProAir, or
Proventil (albuterol).
- Healthcare providers may also prescribe an inhaler or a nebulizer treatment to help
loosen the mucus in the lungs and help you breathe better. The most common
medication for this is Ventolin, ProAir, or Proventil (albuterol).

c. Philips Cough Assist Device for airway clearance

- The cough assist helps to clear secretions by applying a positive pressure to fill the lungs,
then quickly switching to a negative pressure to produce a high expiratory flow rate and
simulate a cough.[2] It is known as ‘manual insufflation-exsufflation’ and can be applied
via a mask, mouthpiece, endotracheal, or tracheostomy tube.

d. Breathing Exerciser Breathe Trainer Vital Capacity Pulmonary Function Rehabilitation

Physical Training Device
- Like aerobic exercise improves your heart function and strengthens your muscles,
breathing exercises can make your lungs more efficient.

e. CPAP
 - CPAP stands for “continuous positive airway pressure.” A CPAP machine delivers a
constant inhalation (breathing in) pressure and exhalation (breathing out) pressure. This
constant pressure keeps the airway open between breaths, and is a perfect tool for a
person who has obstructive sleep apnea.

f. BiPAP
- A bilevel positive airway pressure, or BiPAP, machine, delivers two different pressures: a
higher pressure during inhalation to help push air in, and a lower pressure during
exhalation to help air breathe out.

g. The Vest
- The Vest, or high-frequency chest wall oscillation, is a technology employing an inflatable
vest connected by an air hose to a pulse generator. The Vest rapidly inflates and
deflates, applying gentle pulsed pressure to the chest wall. The aim is to generate
“shearing force” between the mucus and the lining of the airways, with the intention of
dislodging these secretions that can subsequently be coughed and cleared.

5. Look for a journal /related studies relevant in the case scenario.

Pneumonia is one of the primary causes of morbidity and mortality in elderly patients due to
infection. The increasing prevalence of pneumonia in the elderly can be attributed to physiological
changes associated with the aging of the respiratory tree and a decreased immune response. A
chain of events leads to weakness, infection, and death; avoiding pneumonia entails addressing
the risk variables. Dysphagia, which is related with malnutrition and dehydration, is recognized as
a primary pathophysiological process leading to pneumonia, and its screening is critical for
determining pneumonia risk.
Pneumonia prevention begins with lifestyle changes such as quitting smoking and drinking
alcohol. In elders with various morbidities, a comprehensive examination of the risk–benefit ratio
of the given drug is crucial, and customization may be required. Respiratory physiotherapy and
 mobilization enhance functional status and, as a result, may help lower the risk of pneumonia.
Maintaining teeth and masticatory effectiveness is critical for avoiding malnutrition and its
repercussions. Daily dental hygiene and expert removal of oral biofilm can help to prevent the
establishment of periodontitis and avoid an oral environment that encourages the colonization of
respiratory infections, which can subsequently be inhaled into the lungs.
Reference:
Chebib, N., Cuvelier, C., Malézieux-Picard, A. et al. (2021). Pneumonia prevention in the elderly
patients: the other sides. Aging Clin Exp Res 33, 1091–1100. Retrieved from: .
https://doi.org/10.1007/s40520-019-01437-7
6. Analyze the scenario for a case presentation at the end of the rotation.
Pneumonia is one of the primary causes of disease in older patients due to infection. The growing
cases of pneumonia in older adults can be attributed to physiological changes associated with the
aging of the respiratory tree and a decreased immune response. Age is one of the most
significant known risk factors for Pneumonia.
So, because the patient always took care of her dog and brought it outside of their house even in
the middle of cold winter air, the patient contracted microorganisms that caused Pneumonia.
Streptococcus pneumoniae and Mycoplasma pneumoniae are the microorganisms that cause
infection. Streptococcus pneumoniae normally develops on its own after the patient has a cold.

References:
https://www.medicalnewstoday.com/articles/315713#Understanding%20the%20connection
https://www.healthline.com/health/pneumonia#symptoms
https://www.physio-pedia.com/Assisted_Coughing
https://www.medicalnewstoday.com/articles/incentive-spirometer#how-it-measures
https://blog.lptmedical.com/nebulizer-therapy-what-you-need-to-know-to-get-started
https://www.parentprojectmd.org/care/care-guidelines/by-area/care-for-lung-muscles/assistive-devices-
for-breathing/
https://link.springer.com/article/10.1007/s40520-019-01437-7#citeas