Medical case

(Pneumonia)
Scenario

Mr Chan, 70 years-old man, accompanied by his wife, arrived A&E after 5 days of
fever, headache, generalized body pain and productive cough. He has prescribed
antipyretic, cough syrup after consulting GP.

Initially, his symptoms was improved after taking the medication, but he has had
more difficulty breathing, high fever, chills, generalized body pain, increased sputum
production in the past 2 days and has been using inhaler with no improvement, so
he admitted to the hospital.
Past medical history:

1. Hypertension for 5 years on Norvasc 5 mg QD FU GOPC

2. COPD for 5 years on Albuterol-Ipratropium inhaler one spray QID, Pulmicort
two puff BD, Fluimucil 200 mg TDS

Past surgical history: Nil

Allergic history: NKDA

Social history:

➢ Lives with wife, no children

➢ Chronic smoker (1 pack cigarette per day), beginning at age 14
Mr Chan’s vital signs at A&E

➢ BP: 128/78 mmHg

➢ P:115/min
➢ RR: 26/min
➢ Temp: 38.5 oC Tympanic
➢ SpO2: 88 % on room air
Question 1 (Short Question)
What further questions you would like to ask for collecting more circumstantial
information?
Answer:
➢ FTOCC
➢ Conscious level
➢ Onset of SOB and for how long
➢ Any recent infections, e.g. URTI
➢ Productive/non-productive cough
➢ Any chest pain during coughing
➢ Amount and color of sputum
➢ The highest temp in last week
➢ Last dose of antipyretic drug taken
➢ Any other related symptoms such as muscle pain, headache, etc
➢ Any past medical /surgical history
➢ Any known allergy including food and drug
The doctor conducted respiratory examination for Mr. Chan:

➢ FTOCC -ve
➢ Respirations shallow and laboured, use of accessory muscles, green phlegm
➢ Increased AP diameter of chest
➢ Dullness to percussion
➢ Skin dry and warm touch, inelastic skin turgor, fingernail clubbing
Question 2

Which assessment is most important for doctor to complete next?

A. Auscultate breath sound

B. Palpate the abdomen
C. Check the legs and ankles for any signs of swelling
D. Inspect the jugular vein
Answer: A

➢ In addition to inspection, palpation and percussion, auscultation is an

important component in a thorough respiratory examination
➢ Because infections and other conditions in the lungs commonly cause
unusual breath sounds can be heard through auscultation, therefore answer
B, C & D are incorrect choices as a first action
 Physical examination:
- Occasional wheezing and crackles on right lung

CXR result:
- Moderate haziness on RMZ of lung

https://radiopaedia.org/cases/right-upper-lobe-pneumonia-8
Question 3
What is Mr Chan’s most likely diagnosis according to the initial assessment?

A. Tuberculosis
B. Pneumonia
C. Influenza
D. Common cold
Answer: B
➢ Patients with typical community-acquired pneumonia classically present with
fever, a productive cough with purulent sputum, dyspnea, pleuritic chest pain,
muscle pain, tachycardia and trouble breathing
➢ Mr. Chan’s CXR also showed mild haziness on RMZ of lung and occasional
wheezing and crackles was heard during auscultation of lung sound indicates
pneumonia
Question 4
Mr. Chan with a history of COPD is experiencing dyspnea. The nurse plans to
administer oxygen as prescribed. Which statement is true concerning oxygen
administration to Mr. Chan?

A. High oxygen use will cause Mr. Chan become dependent on the oxygen.
B. High oxygen concentration will cause coughing and dyspnoea.
C. High oxygen concentration may inhibit the hypoxic stimulus to breathe.
D. High oxygen concentration will cause brochodilatation.
Answer: C
➢ Mr. Chan with a history of COPD may retain more CO2 , therefore the major
respiratory stimulant becomes hypoxemia
➢ Therefore, high O2 level no longer stimulate the respiratory center and lead to
apnoea
Treatment ordered by A&E doctor:
➢ 2L/min Oxygen → SpO2 increased to 91 % on 2L/min N.C.

Mr Chan was then admitted to general medical ward for evaluating high fever and
SOB.
Question 5
Mr Chan is admitted to medical ward, what is your immediate action after
transferring Mr. Chan from a stretcher to bed?

A. Check vital signs

B. Make sure the nasal cannula is well connected to the oxygen flow meter
C. Inform a houseman for new admission
D. Ask Mr. Chan’s wife to get change the pyjamas for him
Answer: B
➢ This is the highest priority because Mr. Chan is clear exhibiting respiratory
distress which required oxygen supply to maintain his saturation to 90 %
Question 6 (Short Question)

What diagnostic tests should be ordered for Mr. Chan?

Answer:
➢ Blood tests including complete blood picture, LFT, RFT, etc
➢ Chest x-ray (done in A & E)
➢ Arterial blood gas (ABG)
➢ Sputum culture
➢ Urine culture
➢ Blood culture
➢ NPA
Here is the treatment order:
- Soft diet
- 2D1S Q6H
- BP/P, SpO2 Q4H (Keep SpO2 > 90%)
- 2L O2 NC
- Septic workup
- NPA
- ABG, L/RFT, CBC, FG
- Chest physiotherapy
- CXR (already done in AED)
- Fluimucil 200 mg TDS
- Norvac 5 mg QD
- Albuterol-ipratropium inhaler one
spray QID
- Pulmicort two puff BD
- IV Hydrocortisone 100 mg Q8H
- IVI Augmention 1.2g Q8H
- Pre & post PFR BD
Question 7
Which nursing action should be implemented before Augmentin is administered?

A. Check vital signs

B. Administer albuterol-ipratropium inhaler
C. Perform septic workup
D. Recheck ABG
Answer: C
➢ The septic workup will be compromised if broad-spectrum is taken first
➢ Septic workup including blood, sputum and urine culture (CXR, WBC)
➢ +/- Sputum if patient unable to cough out sputum
Question 8
The doctor has prescribed IV Augmentin empirically for Mr. Chan. Which of the
following is an adverse effect associated with the medication?

A. Toxic epidermal necrolysis

B. Hyperuricaemia
C. Hyperglycaemia
D. Ototoxicity
 Answer: A
➢ One of the adverse effect of administering augmentin is toxic epidermal
necrolysis which is a serious skin reaction that causing extensive peeling of
the skin (more than 30% of the body surface)

Source from: https://en.wikipedia.org/wiki/Toxic_epidermal_necrolysis#/media/File:TENS_patient_on_day_10.jpg

Here is the ABG result:

pH 7.26 (7.35 – 7.45 )

PaO2 70 mmHg / 9.33 kPa (80 – 100 mmHg / 10.7 -13.3 kPa)

PaCO2 61 mmHg / 8.13 kPa (35 – 45 mmHg / 4.7 – 6.0 kPa)

HCO3- 23.6 mEq/L (22 – 26 mEq/L)

BE +1 (- 2 to + 2 )
Question 9
Regarding to the ABG result, what is your interpretation?

A. Non-compensated respiratory acidosis

B. Partially-compensated respiratory alkalosis
C. Non-compensated Metabolic acidosis
D. Partially-compensated Metabolic alkalosis
Answer: A
➢ The ABG result indicates that Mr. Chan is experiencing non-compensated
respiratory acidosis with mild hypoxaemia
➢ pH 7.26 indicate that acidosis is present
➢ The elevated paCO2 (61 mmHg / 8.13 kPa) indicates that the problem is
respiratory in nature
➢ Since both HCO3 and BE are normal → no compensation
➢ Respiratory acidosis is caused by inadequate elimination of CO2 in the lungs
due to pneumonia
➢ Even though Mr. Chan has rapid RR (26/min), his underlying COPD causes
CO2 retention
Question 10
Due to the abnormal ABG result, what is the nursing management for patient
respiratory acidosis?

I. Position Mr. Chan with upright position or semi-Fowler’s position

II. Maintain an oxygen administration device as ordered
III. Monitor oxygen saturation at 90% or greater
IV. Encourage deep breathing and coughing exercise
A. I, II & III
B. II, III & IV
C. I, III & IV
D. All of the above
Answer: D
➢ Upright position or semi-Fowler’s position allows increased thoracic capacity,
and increased lung expansion
➢ Supplemental oxygen may be required to maintain PaO2 at an acceptable
level
➢ When administering oxygen, close monitoring is imperative to prevent unsafe
increases in the patient’s PaO2 which could result in apnea
➢ Deep breathing and coughing exercise promotes deep inspiration and
increase sputum clearance, which increases oxygenation and prevents
atelectasis
Pursed-lip breathing
Pursed lips breathing
Diapharmatic breathing

http://copd2017.com/index.php/breathing-techniques/
Question 11 (Short question)
What is the rationale for administering IV Hydrocortisone to Mr. Chan and what is its
side effect?
Answer:
➢ Mr. Chan is presently experiencing community-acquired pneumonia as evidenced by
wheezing, cough, and dyspnea. Hydrocortisone is a corticosteroid and has potent anti-
inflammatory actions and also suppress the immune response
➢ It has been used therapeutically for treating a wide variety of autoimmune, rheumatologic,
inflammatory, neoplastic and infectious diseases, reactive airway diseases, COPD, and
infectious disorders (such as laryngotracheobronchitis)
➢ Side effects with long-term use include osteoporosis, osteonecrosis, unusual weight gain,
abnormal fat deposition, depression, psychosis, ankle and foot swelling, elevated risk of
fractures, hyperglycaemia, cataracts, Cushing's syndrome, weakness, easy bruising, and
increase susceptibility to infections, etc.
Question 12
What drug classification is Albuterol and Ipratropium inhaler?

A. Anticholinergic
B. Bronchodilator
C. Antibiotic
D. Anti-arrhythmia
Answer: B
➢ Albuterol and Ipratropium are bronchodilators that relax muscles in the airway
and increase airflow to the lungs
Question 13 (Short Question)
Which nursing assessment is most important to perform while Mr. Chan is
receiving Albuterol and ipratropium?
Answer:
➢ Assess Mr. Chan’s pulse and respiratory status, because beta adrenergic
agonist replicates sympathetic stimulation, Mr. Chan should be assessed for
palpitation, restlessness, tremor, tachycardia, etc.
➢ Check allergy history
➢ Assess Mr. Chan’s knowledge on how to use Albuterol and ipratropium
inhaler.
➢ Prop up Mr. Chan for better lung expansion.
➢ Check pre & post PFR to evaluate the effectiveness
of current treatments

https://en.wikipedia.org/wiki/Peak_expiratory_flow
 Prepare for first use of combivent (Information)

https://docs.boehringer-ingelheim.com/Prescribing%20Information/PIs/Combivent%20Respimat/CMVTRSPT.pdf
https://docs.boehringer-ingelheim.com/Prescribing%20Information/PIs/Combivent%20Respimat/CMVTRSPT.pdf
Daily use of combivent respirant (Information)

https://docs.boehringer-ingelheim.com/Prescribing%20Information/PIs/Combivent%20Respimat/CMVTRSPT.pdf
How to Use a Peak Flow Meter (Information)
➢ Stand up or sit up straight
➢ Make sure the indicator is at the bottom of the meter (zero)
➢ Hold the flow meter horizontally
➢ Take a deep breath in, filling the lungs completely
➢ Place the mouthpiece in the mouth; lightly bite with the teeth and close the
lips on it (Be sure the tongue is away from the mouthpiece)
➢ Blast the air out as hard and as fast as possible in a single blow
➢ Remove the meter from the patient’s mouth
➢ Repeat three times and record the best reading
➢ Repeat steps post inhalation and record the reading

https://www.healthline.com/health/peak-expiratory-flow-rate#process
Video:
How to use Respirmat:
https://www.youtube.com/watch?v=zFKe6FVdQ2M
正確使用吸入器 – Spiolto Respimat 輕霧吸入器:
https://www.youtube.com/watch?v=Fsw7j6QwCzQ

Using inhaler medications: http://copd2017.com/index.php/copd-

medications/using-inhaler-medications/
Question 14 (Short Question)
The nurse monitored of Mr. Chan SpO2 indicates readings between 88 - 89 % on
2L O2 (keep SpO2 > 90 % as prescribed). After checking the sensor site to make
sure the readings are accurate, which intervention should the nurse take
immediately?
Answer:
➢ Assess Mr. Chan’s respiratory condition and conscious level
➢ Assess adequacy of finger’s circulation prior to applying the sensor
➢ Assess for any sputum retention and perform suctioning if necessary
➢ Make sure proper functioning of equipment by:
○ Attaching oxygen tubing to nozzle on flowmeter
○ Turning on the oxygen at the prescribed rate
○ Checking that oxygen is flowing through tubing
○ Placing cannula prongs into nares with prongs curving downward
➢ Elevate the head of bed to semi to high-Fowler's positions so as to decrease
the pressure on diaphragm and allow from improved lung expansion
➢ Teach Mr. Chan while taking inhale and exhale through pursed-lip breathing
➢ Inform the doctor if Mr. Chan’s condition has not improved
Question 15
Which type of precaution is required for a nurse to obtain NPA for Mr. Chan?

A. Contact precautions
B. Airborne precautions
C. Droplet precautions
D. Hand hygiene
Answer: B
➢ Nasopharyngeal aspiration (NPA) are theoretically at risk of dispersal of
infectious respiratory droplets
➢ Airborne precaution should be added for the aerosol-generating procedures,
e.g. NPA, Intubation, CPR...
➢ Full PPE protections applied whenever samples are obtained from patient
➢ Recommended PPE Alert / Serious response level (S1):
○ Surgical mask / N95 respirator, face shield / eye protection, isolation gown, gloves
➢ Serious Response level (S2) / Emergency response level (E):
○ N95 respirator, face shield/eye protection, isolation gown, gloves, cap (optional)

Recommended PPE for routine patient care and performing aerosol-generating procedure:
https://www.chp.gov.hk/files/pdf/recommended_ppe_in_hospitals_clinics_under_different_response_levels_emerging_respiratory_tract_id_eng.pdf
How to obtain NPA? (Discussion)
➢ Explain the procedure to Mr. Chan
➢ Perform hand hygiene and put on PPE
➢ Prop up Mr. Chan with head tilt position
➢ Measure the insertion length of catheter
➢ NPA are aspirated through a catheter connected to a mucus extractor and fitted to a
vacuum source
➢ Turn on suction and adjust to suggested pressure (80-120 mmHg)
➢ The catheter is inserted into the nostril parallel to the pharynx till reached the posterior
pharynx without suction
➢ The vacuum is applied and the catheter is slowly withdrawn with a rotating motion (less
than 10 seconds)
➢ After mucus has been collected, the catheter is flushed with 3 ml of viral transport medium
(TM bottle)
➢ Well label the specimen bottle after verify Mr. Chan’s identity and sent to microbiology lab
 https://www.berkshireandsurreypathologyservices.nhs.uk/Cor
http://www.pahsco.com.tw/product_detail-136 e-Service/Test-
Directory/microbiology/CollectingVacuumAssisted.aspx
Nasopharyngeal swab (NPS)
Preparation:

- Flocked swab
- Transport Medium (TM) bottle
- PPE according to guidelines

video: https://www.youtube.com/watch?v=mzs9c37N9RY
Nasopharyngeal Swab (NPS)
Collection procedures:

➢ Cover patient’s mouth with surgical mask

➢ perform hand hygiene and wear PPE
➢ Sit up the patient and tilt patient’s head back slightly
➢ Gently insert the swab into nasal passage until resistant felt. To determine proper
placement of the swab, it‘s about the distance from the tip of the nose to the earlobe
➢ Rub back and forth nasal turbinate about 5 times or rotate the swab for several times,
hold for about 10 seconds to dislodge respiratory epithelial cells and then remove the
swab
➢ insert the flocked swab into the TM bottle
➢ Break the shaft at the painted break point and screw tightly, then gently agitate the
container
➢ Label the specimen properly and send the specimen as soon as possible.
Mr. Chan has not responded to bronchodilation therapy, intravenous augmentin
and corticosteroids. Few days later, his condition is deteriorated. His vital signs is
as follow:

BP 145/99 mmHg

P 120/min, weak and thread

RR 35/min, rapid and shallow

SpO2 78 % on 2L O2 via NC

T 37.8 oC Tympanic

WBC result 14 (normal range 3.89 - 9.93 10^9/L)

Question 16
What is the most appropriate step in Mr. Chan’s management?

A. Give ice bag to lower the temperature

B. Administer extra dose of Albuterol and Ipratropium inhaler
C. Recheck the vital signs
D. Inform the doctor and increased oxygen as prescribed
Answer: D
➢ This is the top priority to inform the doctor and increase the oxygen level at
once because Mr. Chan’s saturation is dangerously low
➢ Besides, the nurse should also:
○ Assess Mr. Chan’s conscious level and general condition
○ Maintain the Mr. Chan’s airway patency by removing any secretion if present
○ Keep him in high Flowler position
○ Make sure the bed side rail is pull up to maintain his safety
○ Monitor Mr. Chan’s respirstory status. e.g. SpO2, RR, etc.
Informing doctor
I: Dr, Here is ward B2 bed 1 patient Mr. Chan, 70/M, admitted for pneumonia, fever,
SOB

S: Patient developed desaturation, SaO2 78% on 2L/min N.C. , BP 145/99 mmHg,

P 120/min, RR 35/min, shallow and rapid breathing, Temp 37.8oC Tympanic

B: History of COPD & HT. After admission, started iv Augmentin and

Hydrocortisone and puff given.

A: GC drowsiness, suction done, already propped up the patient, but no

improvement, septic workup done (tracing result), WBC 14 10^9/L.

R: Increase O2?, any more investigation test? ABG/CXR, Please come and assess
the patient. I will prepare...
The doctor prescribed O2 100 % via non-rebreather mask and Mr. Chan’s
saturation is temporary returned to 88 %. Urgent ABG & CXR are ordered. His
NPA, urine and blood culture results are normal except his sputum culture result:
Mr. Chan’s sputum culture result:

Gram Stain: Gram +ve cocci

Purulent with few epithelial cells
Culture:
Organism: Streptococcus pneumoniae (heavy)

Antibiotics Organism

Amoxicillin + Clavulanate S
Ampicillin R
Ceftriaxone R
Cefuroxime R
Co-trimoxazole R
Gentamincin R
Piperacillin + Tazobactum S
Question 17

According to his abnormal sputum result, fever and WBC, other than IV
Augmentin, which of the following is the most appropriate antimicrobial regimen
for Mr. Chan?

A. Co-trimoxazole
B. Gentamicin
C. Ceftriaxone
D. Piperacillin + Tazobactam
Answer: D

➢ Piperacillin + Tazobactam is broadest-spectrum antibiotics and is sensitive to

Streptococcus pneumoniae, which plays an important role in the empiric
therapy of serious infections
➢ Both Co-trimoxazole, Gentamicin & Ceftriaxone are resistant to the causative
bacteria, therefore answer A, B & C are incorrect
➢ Monitor Mr. Chan’s RFT as well
Although IV Tazocin 4.5g Q8H is started, Mr. Chan marked increase in symptoms
and then was found unconscious. Latest CXR result revealed increased bilateral,
diffuse lung opacities.

Vital signs:

BP 100/47 mmHg

P 128/min

SpO2 76% on 100 % O2

Urgent ABG is done while Mr. Chan is on the non-rebreather mask:

pH 7.00 (7.35 – 7.45 )

PaO2 50 mmHg / 6.66 kPa (80 – 100 mmHg / 10.7 -13.3 kPa)

PaCO2 112 mmHg / 15 kPa (35 – 45 mmHg / 4.7 – 6.0 kPa)

HCO3- 30 mEq/L (22 – 26 mEq/L)

BE +6 (- 2 to + 2 )
Question 18

Regarding to the ABG result, what is your interpretation?

A. Non-compensated respiratory acidosis

B. Partially-compensated respiratory acidosis
C. Mixed Respiratory and Metabolic alkalosis
D. Compensated metabolic alkalosis
Answer: B
➢ The ABG result indicates that Mr. Chan is experiencing partially-compensated
respiratory acidosis with moderate hypoxemia
➢ PH is 7.00 which is below the midpoint (7.4) of normal range and PaCO2 is
15 Kpa (4.7-6) therefore the primary status of PH imbalance is respiratory
acidosis and HCO3- is 30 (22-26) the compensating is metabolic alkalosis
➢ Both PaCO2 & HCO3- are abnormal and because the compensation is
incomplete, therefore the pH is abnormal (7.00)
➢ Further deterioration of Mr. Chan’s respiratory condition by inadequate
elimination of CO2 in the lungs due to severe pneumonia, poor lung
compliance due to atelectasis and increased thick, frothy sputum, he is
suffered from hypercapnic respiratory failure
Question 19

According to Mr. Chan’s condition, which of the following are considered as the
most appropriate management for him?

A. Insert foley catheter

B. Administer IV gelofusine infusion
C. Start a peripheral dopamine
D. Prepare for endotracheal intubation
Answer: D

➢ Preparation of endotracheal intubation is essential as Mr. Chan’s is suffering

from hypercapnic episode although maximum of 100% oxygen is given
Question 20 (Short Question)
Due to clinical instability, Mr. Chan required endotracheal intubation. What should
the nurse prepare for Mr. Chan next?
MEDICAL EQUIPMENT
Contributor: BSIP SA / Alamy Stock Photo
Answer:
➢ I: Ensure the availability and patency of IV access
➢ S: Ensure suction equipment is ready
➢ T: Prepare intubation equipment e.g. laryngoscope, ETT, Stylet, Syringe,Tape...
➢ O: Ensure oxygen is ready
➢ P: Position the patient
➢ M: Cardiac monitoring, Monitor Mr. Chan’s condition (e.g. vital signs, SaO2 etc.) during
the procedure
➢ A: Assistant e.g. BVM, Ventilator is ready with prescribed setting
➢ D: Prepare sedative agent and muscle relaxant for intubation if needed

After care:
➢ Documentation
➢ Inform Mr. Chan’s relatives
➢ ICU consultation, Prepare transfer memo if ICU takeover
➢ Post-intubation CXR
How to intubate a patient
https://www.youtube.com/watch?v=cLL6XwhFEFQ
Thank You