Question

CLINICAL SCENARIO

NURSING HEALTH HISTORY

A. Patient’s Profile

Name: JFK

Birthday: August 23, 1982

Age: 38 years old

Sex: Male

Nationality:Filipino

Religion:Roman Catholic

Marital Status:Married

Address: Pampanga

Date of Admission: September 02, 2020

Time of Admission: 2:30PM

Chief Complaint: productive cough with fever with slight difficulty of breathing

Final Diagnosis: Moderate Risk Community Acquired Pneumonia (CAP III)

History of Present Illness :

Patient came to the hospital complaining of productive cough, fever and slight difficulty of breathing. Client is having persistent productive cough with greenish phlegm and has had fever with 39.3 celcius for temperature when admitted. The client is ambulatory, coherent and v/s results showed an elevated RR of 37 cpm, pulse rate of 104. On DAT was prescribed, has a standing order of TSB for fever. WBC count is within range, CXR results showing consolidation and sputum culture and sensitivity shows S. pneumoniae with a medical diagnosis of CAP III.

Past Medical History :

Cough and fever has been noted to have onset 4 days prior to admission. Client has history of pneumonia and was admitted to the hospital when he was in high school. Client has suffered asthmatic attack when he was 3 years old and was admitted to the hospital and was given Ventolin for treatment but has no record of any onset after that.Immunizations were completed when he was one year old.Latest medicines prescribed are Cefuroxime, Albuterol, Montelukast, and Naproxen. The patient never undergone any type of surgery. He has no known allergy to food and medication.Family History(+) Hypertension-father(+) Diabetes Mellitus-father(-) Cancer(+) PTB-mother

Personal and Social History : Patient is a tricycle driver and a very joker person, he mingles with his co-tricycle drivers, friends, and neighbors. Patient is non-smoker, non-drinker and no history of taking illicit drugs. He prefers to eat rice, fish and vegetables, but sometimes eat in a sari-sari store. He enjoys talking to commuters and taking care of his children when his day-off, his leisure time is watching TV with his family. If the patient has free time from driving, he likes going to mall with hisfamily every Sunday after church. He is a sweet and loving husband to his wife and children.

Admission Order Medication: Cefuroxime (Zinacef) 750 mg every 8 hours TIV Levofloxacin (Levox) 500 mg 1 tab OD PO Paracematol1 amp TIV for temp of equal or greater than 38.6 and paracetamol 500mg tab PO for temp of 38.5 below Berodual nebulization (10gtts in 3 ml NSS) every 6 hour

Therapeutics: IVF PNSS 1L to run for 8 hours at 31-21 gtts per min at left arm

Bedside O2 of 3L/min via nasal cannula

Nebulization followed by CPT

Bedside Care: Vital signs every shift and watch out for any signs of dyspnea progression, bed rest, I and O monitoring, suction secretions when necessary, provide comfort, morning care done, side rails up for safety, assess every now and then and relayed any abnormal symptoms and complications

COURSE TASKS:

1. Make an Anatomy and Physiology of Community Acquired Pneumonia III.

2.Conceptualize the pathophysiological alterations distinct to the case.

✓Establish the pathophysiological triad of Host –Agent –Environment specific to the case.

✓Trace the pathophysiological changes and highlight problems that are experienced by the client.

✓Connect the pertinent nursing care and medical –surgical management to the various signs and symptoms presented by the client.

Answer 1

Pneumonia is the inflammation of the lung parenchyma.Community acquired pneumonia is the type of pnemonia, that the individual develops from the community where he lives. Its usually developed outside the hospital. Various organisms are invoived in the development of community acquired pneumonia. They includes,streptococcus pneumoniae, influenza A etc.

Based upon the anatomy of pneumonia, its classified into

• Lobar pneumonia- The type of pneumonia, wher all the lung lobes or a large segment of one or more pulmonary lobe is infected with pnemonia and it is characterized by areas of consolidation.
• Bronchopneumonia-This begins in the terminal bronchioles, which become clogged with mucopurulent exudate to form consolidated patches. Usually affect the alveolis also.
• Interstitial pneumonia-In this type of pneumonia, the inflammatory process is more confined within the alveolar walls and the peribronchial tissues.

Conceptualize the pathophysiological alterations distinct to the case.

✓Establish the pathophysiological triad of Host –Agent –Environment specific to the case.

the epidemiological triad consist of host, agent and environment. This is a model, that helps to explain about the disease causing organism,the disease and the environmental factors that aids in the progression and spread of the disease.

• Agent: The agent is the microorganism that causes the disease in a healthy individual. An agent may be bacteria,virus, fungus, or parasite. here the agent is  S. pneumoniae .
• Host: The host is the living animal that carries the disease. A host doesn’t need to get sick everytime. Sometimes hosts may remain as carriers without showing any symptoms of the disease. Here human being( the patient itself become the host).
• Environment: The factors that can affect the spread of the disease is called as the environment. Here environment includes, the area where he works, esspecially as a driver exposed to environmental risk and visiting malls on weekends(may be polluted area and over crowded)

✓Trace the pathophysiological changes

The pathophysiology of Pneumonia is classifeied in to different stages such as consolidation stage, red hepatization stage and grey hepatization stage and resolution stage.

1. Consolidation stage

This is the first stage, usually occurs in the first 24 hours after the infection. Where following the infection,Cellular exudates containing neutrophils, lymphocytes and fibrin replaces the alveolar air.Capillaries in the surrounding alveolar walls become congested and the infections start spreads to the hilum and pleura rapidly. As a result pleurisy occurs, severe pain while breathing. This stage is characterized by Marked by coughing and deep breathing. The chest parenchyma may filled with exudates and discahrge leading to consolidation patches.

2. Red Hepatization stage

This stage develops within the 2-3 days after consolidation. At this point the consistency of the lungs resembles that of the liver, hence it got the name of red hepatizaion.The lung parenchyma become hyperaemic due to increased blood flow. This may cause the alveolar capillaries are engorged with blood.This stage is characterized by the presence of many erythrocytes, neutrophils, and fibrin within the alveoli to start the phagocytosis process.

3. Grey Hepatization stage

this stage Occurs in the 2-3 days after Red Hepatization. This is an avascular stage characterized by decreased blood supply to the lung parenchyma due to this the lung appears gray-brown to yellow in colour. the lung parenchyma may filled with fibrinopurulent exudates.The pressure of the exudates in the alveoli causes compression of the capillaries

4. Resolution stage

This is the final stage, and is characterized by restoration of the pulmonary architecture. For that a large number of macrophages enter the alveolar spaces and begins with Phagocytosis of the bacteria. As a result, the consolidation tissue re-aerates. Fluid infiltration causes the development of sputum

Highlight problems that are experienced by the client.

Here the client is having problems such as productive cough, fever and slight difficulty of breathing. fever is due to the inflammatory process, as the alveoli and lung lobes filled with mucopurulent discharge and exudates from the inflammatory process, the individual will experience productive cough, and this may inyterfere with the normal oxygenation process. This is characterized by brathing difficulty.That why he exhibited the symptoms of  persistent productive cough with greenish phlegm and has had fever with 39.3 celcius for temperature when admitted. The v/s results showed an elevated RR of 37 cpm, As the breathing difficulty progresses, respiratory rate also tends to high. WBC count is within range, which can elevate in the upcoming days, CXR results showing consolidation in the lung lobes.Consolidation patches are developed here because of the normal lung parenchmal tissues are replaced with pus, muco purulent discaherge and exudates from inflmmatory process.

Connect the pertinent nursing care and medical –surgical management to the various signs and symptoms presented by the client.

Nursing care management

• Asess the respiratory rate of the patient.
• Assess the vital signs of the patient.
• Supplemental oxygen may be required if oxygenation status is compromised.
• Assess respiratory rate and oxygenation status, as well as vital signs, pain level, and general disposition and level of activity etc
• To prevent dehydration, fluids are frequently administered intravenously during the acute phase.
• If needed, supplemental oxygen may be administered by nasal cannula or face mask.
• Encouraged to allow appropriate rest and discourage vigorous activities .

Surgical management

• Continuous closed chest drainage may be instituted when purulent fluid is aspirated.Usually performed if the patient cannot spit out the sputum by self.
• Administration of a Closed drainage until drainage fluid is free of pathogens,
• Repeated pleural taps to remove fluid.
• Thoracotomy can be performed with open debridement of the infected lung tissue
• partial thoracoscopic lobectomy  if empyema and pneumothorax develops

Medical managemnet

• Oral or IV antibiotics as per culture results and patients weight (Cefuroxime (Zinacef) 750 mg every 8 hours TIV Levofloxacin (Levox) 500 mg 1 tab OD).
• Antipyretics to reduce the body temperature( Paracematol1 amp TIV for temp of equal or greater than 38.6 and paracetamol 500mg tab PO for temp of 38.5 below )
• Broncho dilators inorder to enlarge the airway and to reduce the spasm of the airway(Berodual nebulization (10gtts in 3 ml NSS) every 6 hour)
• Fluid- electrolyte administration: IVF PNSS 1L to run for 8 hours at 31-21 gtts per min at left arm
• Supplimental oxygen therpay (Bedside O2 of 3L/min via nasal cannula)
• Nebulization
• CPT
• Postural drainage