Question

You are working in A&E where you are allocated to assess and care for . Mr Smith is a 35-year-old man who became unwell with community acquired pneumonia (CAP). Smith went to his local GP a week ago with a fever, difficulty breathing and a productive cough. At that time, the GP diagnosed Smith as having pneumonia and prescribed a course of oral antibiotics. When the GP assessed John today, he appeared lethargic and drowsy, and stated that he is nauseous and feels “achy all over”. The GP called an ambulance to take Mr Smith to hospital because the antibiotics had not worked, and he was now in acute respiratory distress.

John has a past history of rheumatoid arthritis and is on 25mg oral prednisolone to manage this chronic inflammatory disease.

Your assessment of Mr Smith reveals the following information.

General appearance: pale, diaphoretic, lying against the raised back of the bed (high Fowler’s).

Vital signs: temperature 38.6°C, RR 26 bpm, HR 115bpm, BP 94/65 mmHg, SpO2 92% on RA,

Neurological: lethargic and drowsy, GCS 14. (eye opening to speech, oriented to time, place & person, obeys commands).

Respiratory: Obvious use of accessory muscles. Difficulty speaking to answer questions. Bronchial breath sounds in both bases & course crackles to mid-zones bilaterally. Productive cough (thick, green sputum).

Laboratory and other investigations: CXR shows consolidation in bilateral lower lobes. Blood culture results sent by his GP are positive for pneumococcal. His serum lactate results have come back as 3.4 mmol/L (normal < 1mmol/L), and his WBC is 16.0 x 109/L (normal 4.5-11 x 109/L). C-reactive protein (CRP) 57mg/l

Medical orders: John is diagnosed with sepsis and acute respiratory failure. He is ordered an IV fluid resuscitation bolus, broad spectrum IV antibiotics, 2L O2 via NP to maintain SpO2 > 95%, close monitoring of vital observations and urine output.

Question:

Describe how each of these aspects of the information presented above has led to the diagnosis of sepsis and acute respiratory failure.

Presentation history (2):

Nursing Assessment (3):

• Physical appearance:

• Vital signs:

• Diagnostic tests (2): Blood tests:

Question 2

After reading the case study, you are required to identify three (3) priority nursing problems and provide your rationale for making each of these a priority.

Question 3

After identifying three (3) priority nursing problems in the previous question, you are required to formulate a goal to address each priority nursing problem.

Question 4

After formulating the goal for each priority nursing problem in Question 3, you are required to describe three (3) nursing interventions with rationale that you will implement to achieve each goal.   

Answer 1

History

Mr.Smith, 36 year old male, referred here with respiratory distress.History revealed that he had visited local GP a week ago with the complaints of fever, difficulty breathing and productive cough and diagnosed as community Acquired Pneumonia and prescribed oral antibiotics. A week later,again he was assessed by GP and find he is lethargic  and drowsy also he complained having generalized body pain. He had rheumatoid arthritis and is on T. Prednisone 25mg PO. He is currently diagnosed to have sepsis with acute respiratory failure.He is ordered an IV fluid bolus, broad spectrum IV antibiotics, 2L of O2 via nasal prongs to maintain SpO2 > 95%, close monitoring of vital signs and urine output.

Nursing assessment

On assessment, Mr. Smith conscious, oriented to time , place and person. He  looks lethargic and drowsy, pale and lying in Fowler's position. His GCS score was 14 and obeys commands , maintains eye opening on command. He had breathing difficulty, unable to speak and using accessory muscles.Chest auscultation revealed,bronchial breath sounds in both bases & course crackles to mid-zones bilaterally. Productive cough (thick, green sputum).

Physical appearance : He looks lethargic, drowsy and pale.lying in Fowler's position.

Vital signs : Temperature 38.6°C, RR- 26 bpm, pulse rate= 115bpm, BP =94/65 mmHg, SpO2 92% on RA.

Diagnostic tests:

• Chest Xray-  shows consolidation in bilateral lower lobes.
• Blood culture = positive for pneumococcal.
• Serum lactate =3.4 mmol/L.
• WBC =16.0 x 109/L
• C-reactive protein (CRP) =57mg/

Nursing diagnosis, goal and interventions

Nursing diagnosis	goal	Interventions
Ineffective airway clearance related to consolidation of lung parenchyma as evidenced by crackles, use of accessory muscles, dyspnea.	patient maintains airway patency patient demonstrates effective coughing and air exchange patient experiences normal breath sounds and breathing pattern	Provide high Fowler's position to enhance air entry to lungs. Administer Oxygen 2L/mt to maintain O2 saturation >95% Remove secretions by encouraging coughing or apply suctioning. Administer fluid to regulate fluid balance. offer warm fluids to soothen consolidation and promote expectoration of secretions teach deep breathing exercises and encourage him to perform two to three times a day.
Ineffective breathing pattern related to inflammation and pain as evidenced by use of accessory muscles, drowsiness, dyspnea	patient demonstrate normal breath pattern, breath rate	Administer O2, bronchodialators Provide high fowler's position encourage slow breathing to reduce fatigue monitor SPO2
Acute pain related to inflammation of lung and dissemination of toxins as evidenced by generalized body ache	Patient get relief from pain	Provide analgesics to reduce pain T.Predisone for inflammation due to arthritis Administer fluids to maintain hydration Administer O2 to keep cells oxygenated Assist the patient to meet self care needs .