Part 1.

Concept Map

Cheryl (CAP)

Pathophysiology

Community Acquired Pneumonia is acute infection in the lung caused by microbial agent acquired
from the community. (Olubamwo et al., 2018)
- Inflammation to alveoli
- Attracts neutrophils
- Release of inflammatory mediators and accumulation of exudate, RBC and bacteria.
- Resulting in alveoli filling with fluid and debris and increased production of mucus (airway
obstruction)
- Resulting to decreased gas exchange and exudate can consolidate.
Expected Outcomes: Adequate and normal gas exchange, reduce inflammation and infection

Clinical Manifestations:

- Afebrile
- SOB
- Mild chest pain due to
accessory muscle usage
- Weak, sore, tired
- Low O2 sats
- Reduced oxygen intake
- Risk of airway obstruction
due to fluid obstruction

Components of focused
respiratory assessment
-Patient History includes of chronic smoking and Type 2 Diabetes
-Assess for respiratory rate and examine for signs of respiratory distress, observe breathing pattern,
use of accessory muscles, (Olubamwo et al., 2018)
-Assess cough (amount, colour, consistency as indication of infection and inadequate gas exchange
-Assess and document breathing for wheezing, crackling. Crackles are an indication of fluid in
interstitial/alveolar areas, bronchial breath sounds indicate consolidation.

NURSING MANAGEMENT FOR RECOVERY

Patient should demonstrate

1. Maintenance of adequate hydration and nutrition, energy levels returning to
normal, exhibits no complications
1. Improved airway patency, SaO2 of 95% and above, absence of
tachycardia/tachypnea, absence of breathing discomfort and wheezing
2. Afebrile,
3.

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 4. Intervention 1. Maintenance of adequate hydration and nutrition,
energy levels returning to normal, exhibits no complications
Pharmacological nursing management

IVF – to provide hydration and nutrition; hydration is important to manage fever and reduce fluid loss
Routine Paracetamol – myalgia management
Blood Culture – identification of specific pathogen and prompts administration of antibiotics (Olubamwo et al., 2018)
Medication- Paracetamol for pain management
Morphine
Ondansetron – antiemetics managing nausea
Antipyretics – reduction of fever analgesia
Antibiotics –Antibiotic ( Doxycycline 200mg PO ) treatment helps to rid the body of infection and encourage drug
compliance (Olubamwo et al., 2018)
Suction – to remove excess secretion interfering with gas exchange and slowing recovery.

…Oxygenation
Administering supplemental O2 needed to maintain adequate oxygenation.
2. Improved airway patency, SaO2 of 95% and above, absence of
tachycardia/tachypnea, absence of breathing discomfort and wheezing
Oxygen Management

Monitor supplemental o2 supply and suction from pharmacological nursing management.

Oxygen therapy (humidified)
Physiotherapy
Pulse oximetry monitoring
Encourage patient to sit up in bed. Decreases pressure on chest and allows for adequate lung expansion.
(Olubamwo et al., 2018)
Deep breathing and cough every 2hours to clear airway and expand lung at base.
Recommend upright sitting and sleeping positions to maintain open airway and maximise breathing.
Goal: Patient will experience improved oxygenation.
Comfort Management

Assistance with coughing/deep breathing. Encourage patient to drink ample fluid daily, unless contraindicated.
Promotes removal of secretions, hydrations, and ensures adequate gas exchange and oxygenation.
Monitor intake and output, fluid balance chart. Monitoring for signs of dehydration
Encourage calmness due to pain, fatigue and dyspnea relieving anxiety.

Escalation of Care

MonitorOther interventions
for signs of sepsis,forhypotension,
Escalation of Careweak
rapid/
pulse, high fever onset,
MonitorMultidisciplinary
for symptoms ofTeam
Physiotherapist
-worsening in state of cognitive impairment,
Aesthetician
-SPo2 lower than 90%
Doctor
respiratory and
rate nurse
lower team
than 30Breaths per min
Pathologist
Low BP 90/60
If so alert to MET call/ Code Blue.

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 Part 2. Discussion
A) Clinical Manifestations
Cheryl is currently diagnosed with Community Acquired Pneumonia.
Cheryl’s increased shortness of breath has resulted in a decreased oxygen saturation of
89% upon admission and upon auscultation crackles are to be heard too. This can be due
partially to her history of smoking and Type 2 Diabetes which can cause shortness of
breath(Nadler., 2020). Patients with CAP experience inflammation in the lung due to the
body’s inflammatory response to invading pathogens. This accumulates neutrophils and
plasma exudate into the alveoli specific to the affected lung area. It also accumulates cellular
debris into the alveolar walls, fluid accumulation and thickening of alveolar walls. The alveoli
are thus unable to work efficiently resulting in the lungs decreased ability to extract oxygen
from the air creating the Cheryl’s feeling of dyspnea (shortness of breath) and lowering the
body’s oxygen saturation(Nadler., 2020).

Cheryl also presents with fever with temp of 38.7 degrees and is described as flushed face.
The body’s systemic inflammatory response towards invading microbes is to release
cytokines which cause a displacement to the body’s hypothalamic thermoregulatory centre.
Thus resulting in Cheryl’s elevation of body temperature due to heightened immune system
activity.

The patient also presents with chest pain and coughing upon inspiration. Irritation and
attempted clearance of airways and alveolar walls trigger a cough reflex in the patient. Deep
breathing and repeated coughing related to fluid and obstruction of weakened lung capacity
can cause CAP patients to utilise accessory muscles aggravating the chest causing
pain(Nadler., 2020).

Cheryl also presents with lethargy and myalgia. The body requires a surplus of energy to
combat CAP infection and combined with compromised oxygen intake due to lung
inflammation, leading to energy drainage (Nadler., 2020). Symptoms such as fever and an
elevated immune response causes the hypothalamus to inhibit appetite signals; a lack of
appetite can also exacerbate patient’s feelings of wakness and fatigue as well as their
nutrition levels which are vital to patient recovery (Olubamwo et al., 2018)
.

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 B) Nursing Management Strategies

Nurses should aim to maintain/ improve respiratory function, prevent complications and
support recuperation process. Deep breathing and coughing, as well as chest auscultation
and percussion by the nurse to monitor are vital for Cheryl to improve her airway and
respiratory patency (Cook et al., 2020). By deep breathing and coughing, the patient is able
to facilitate alveolar expansion at the base of her lung and also loosens and expels excess
sputum causing airway obstruction. The nurse may consider using humidification and
ensuring adequate hydration to loosen secretion and improve ventilation(Cook et al., 2020)..
The volume of inspiration should be documented in order to compare against changes in
volume over time. Chest percussion can also be performed by the nurse, effective in
loosening sputum. The nurse can consider patient education so that family members can
perform chest percussion involving them in their recovery process. These strategies are
used in effort to increase airway patency and fluid accumulation.

In order to promote rest and comfort for Cheryl, the nurse should position patients with CAP
with the head of the bed elevated to 30 degrees (Cook et al., 2020).. This promotes lung
expansion, enhance sputum expectoration and decrease breathing labour. An elevated
position enhances pulmonary ventilation and is essential for the patient’s rest and recovery.
In addition to turning and positioning, the patient should also be guided in small mobility
exercises that can rehabilitate and build up her energy and respiratory functionality over
time. It is vital to consider if the patient requires a walker or assistance in order to avoid falls
risk. Prior to discharge, nurse should also consider home physical therapy based on
independent mobility of the patient and safety concerns, perhaps involving Cheryl’s family.
Supplemental oxygen therapy may be used in Cheryl’s circumstance as her oxygen
saturation and respiratory functionality are compromised. To avoid hypoxia in patients,
supplemental oxygen can be supplied through a non-rebreather mask (Allibone et al., 2018)
. Further humidification helps liquefy sputum and prevent drying of nasal passages which
may cause irritation and coughing (Allibone et al., 2018).

In addition to these strategies, adequate hydration and nutrition should always be

considered in the management of CAP. Due to fluid build-up and sputum expectoration,
Cheryl may experience a fluid deficit. In order to manage her fever and fatigue, hydration
and nutritional status are vital. Encouraging fluid replacement by increasing oral intake and
improvement renal function with oral and iv fluids can encourage faster patient recovery and

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 prevent further complications (Cook et al., 2020). The nurse should monitor patient intake
and output in order to gauge how she is recovering. Dietary concerns should be taken into
account, a dietician or nutritionist may be involved in this process of recovery for the patient
as well as their family.

It is important to also provide patient education on the importance of their diet which can
essential in avoiding functional decline, fatigue and muscle atrophy (Olubamwo et al., 2018).
Vital signs should also be monitored every four hours in order for prompt recognition of the
patient’s status change (Metlay et al., 2019).
Focused respiratory assessment is also essential in monitoring the patient’ s improvement in
respiratory functionality, monitoring for presence of crackles or laboured breathing. As Cheryl
is also receiving antibiotic treatment, she should also be monitored for secondary infections
(Catia et al., 2018) due to the nature of antibiotics and alerted to the primary care provider
should they develop.
Lastly, Cheryl and her family should be provided education on basic infection control,
immunisation and hand hygiene to break the chain of transmission of bacteria as part of her
home care. In relation to her CAP recovery, these should also include medication education
related to her antibiotics, breathing exercises to promote volume expansion and secretion
clearance, follow ups to monitor her condition and to avoid smoking reoccurrence as she has
a history of it.

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 References

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 Olubamwo, O. O., Onyeka, I. N., Aregbesola, A., Ronkainen, K., Tiihonen, J., Föhr, J., &

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