.

NCM 112 RLE

BSN LEVEL 3

Case Scenario 1
Care of client with alterations in Oxygenation
Pneumonia

This is a case of a 58 year old male named Mr. Roque who came in the ER per wheelchair accompanied
by his wife with chief complaint of high grade fever and chills and difficulty of breathing. Vital signs
shows a temperature of 38.5ºC, pulse rate 85 bpm, respiratory rate of 28 cpm, blood pressure of
130/80mmHg. Oxygen saturation 90% in room air. Weight -65 kg. Physical examination performed
with the patient in upright position. His findings revealed that there were decreased breath sounds and
with rales/crackles on the left lower lung segments upon auscultation. Occasional productive cough with
yellowish sputum; rapid and shallow breathing. He appears to look restless and pale. Swollen and
inflamed throat was noted. Abdomen, HEENT, skin and extremities are essentially normal. Seen and
examined by Resident on Duty.

1 week prior to admission the patient had cough associated with back pain and has poor appetite. Took
over the counter drugs to relieve his pain/discomfort. Sought consult and was requested a chest x-ray.
Advised admission due to left lung field infiltration. Admission care rendered by ER Nurse.

Past medical history reveals he is hypertensive. He has been a smoker since he was in highschool at an
early age of 18 years old. Consumes 2 sticks of cigarettes per day. Has pollen allergies and frequently
suffers from rhinitis. He works in an office as a consultant and often works overtime. Due to his nature
of work, he is occasionally sent by the manager as a representative of the company to travel places for
any work related activities.

His laboratory results shows: Chest x-ray PA view- left lower lobe infiltration, Sputum culture and
sensitivity positive for Streptococcus Pneumoniae, Hematology result- WBC count: 23.84; RBC count:
4.98; Hemoglobin 150; Hematocrit 0.45; Platelet- 200,000; Neutrophils 0.83; Lymphocytes 0.09;
Monocytes 0.01; Eosinophils 0.01; Basophils 0.1; Urinalysis- Color: Straw; Transparency: Hazy; pH:
5.0; Sp Gravity: 1.015; Albumin: Negative; Sugar: Negative.

Impression: CAP-MR, left lower lung considered

Mr. Roque was treated with IV fluids, antibiotics and oxygen therapy. The following doctor’s order: IVF
of PNSS 1L at 80cc per hour. Paracetamol 500mg tablet, 1 tab rtc every 4 hrs for 24 hours then prn for
fever. Azithromycin 500mg OD for 7 days. Piperacillin + Tazobactam 4.5G IV 1 vial via solulet Q8H
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ANST. Losartan K 50mg/tab 1 tab OD. Sodium ascorbate + zinc 500mg/10mg tab OD after breakfast.
Acetylcysteine 600mg 1 effervescent tablet to dissolve in 30ml of water OD HS. Oxygen Inhalation at 2
liter/min. PAI with Salbutamol sulfate 1mg/ml 1 nebule TID, then chest physiotherapy thereafter.
Monitor vital signs; increase fluid intake; activity as tolerated.

After medical and respiratory treatments Mr Roque’s condition improved. Intravenous antibiotics and
oxygen inhalation were discontinued after 7 days. Vitals signs were stable and within normal limits.
There were occasional non-productive cough and less rales noted upon auscultation by ROD and
consultant. He was oriented and instructed of going home medications and care. The following meds:
Paracetamol 500mg 1 tab Q8H PRN for fever, Acetylcysteine 600mg 1 effervescent tablet to dissolve
in 30ml of water OD at bedtime, Azithromycin 500mg/tab for 7 days more. He was advised to have a
follow-up check up after 3 weeks in the doctor’s office. He was grateful for all the nurses and doctors
that attended his care.

Questions:

 List the possible complications that may arise if the condition is left untreated and briefly
describe each.
 Shock and Respiratory Failure
 Severe complications of pneumonia include hypotension and septic shock and respiratory failure
(especially with gram-negative bacterial disease in older adult patients). These complications are
encountered chiefly in patients who have received no specific treatment or inadequate or delayed
treatment. These complications are also encountered when the infecting organism is resistant to
therapy, when a comorbid disease complicates the pneumonia, or when the patient is
immunocompromised.
 Pleural Effusion
 A pleural effusion is an accumulation of pleural fluid in the pleural space (space between the
parietal and visceral pleurae of the lung). A parapneumonic effusion is any pleural effusion
associated with bacterial pneumonia, lung abscess, or bronchiectasis. After the pleural effusion is
detected on a chest x-ray, a thoracentesis may be performed to remove the fluid, which is sent to
the laboratory for analysis. There are three stages of parapneumonic pleural effusions based on
pathogenesis: uncomplicated, complicated, and thoracic empyema. An empyema occurs when
thick, purulent fluid accumulates within the pleural space, often with fibrin development and a
loculated (walled-off) area where the infection is located (see later discussion). A chest tube may
be inserted to treat pleural infection by establishing proper drainage of the empyema.
Sterilization of the empyema cavity requires 4 to 6 weeks of antibiotics, and sometimes surgical
management is required.
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 Pneumococcal Pneumonia
 The onset of pneumococcal pneumonia is generally abrupt and follows an upper respiratory tract
infection. In infants, pneumonia tends to remain bronchopneumonia with poor consolidation
(infiltration of exudate into the alveoli). In older children, pneumonia may localize in a single
lobe, and consolidation may occur. With this, children may have blood-tinged sputum as
exudative serum and red blood cells invade the alveoli. After 24 to 48 hours, the alveoli are no
longer filled with red blood cells and serum but fibrin, leukocytes, and pneumococci. At this
point, the child’s cough no longer raises blood tinged sputum but thick purulent material.
 Chlamydial Pneumonia
 Chlamydia trachomatis pneumonia is most often seen in newborns up to 12 weeks of age
because the chlamydial organism is contracted from the mother’s vagina during birth. Symptoms
usually begin gradually with nasal congestion and a sharp cough; infants fail to gain back their
birth weight. Symptoms progress to tachypnea, with wheezing and rales audible on auscultation.
Laboratory assessment will show an elevated level of immunoglobulin IgG and IgM antibodies,
peripheral eosinophilia, and a specific antibody to C. trachomatis. Such an infection is treated
with a macrolide antibiotic such as erythromycin with good results.
 Lipid Pneumonia
 Lipid pneumonia is caused by the aspiration of an oily or lipid substance. It is much less
common than it once was because children are not given oil-based tonics, such as castor oil or
cod liver oil anymore, as they were in the past. Today it is most often caused by aspirated oily
foreign bodies such as peanuts or popcorn. A proliferative inflammatory response occurs when
lung lipases act on the aspirated oil.
 Differentiate the HAP and CAP.

Hospital-Acquired Pneumonia

HAP develops 48 hours or more after admission and does not appear to be incubating at the time of
admission. VAP can be considered a subtype of HAP, as the only differentiating factor is the
presence of an endotracheal tube (see later discussion of VAP). Certain factors may predispose
patients to HAP because of impaired host defenses (e.g., severe acute or chronic illness), a variety
of comorbid conditions, supine positioning and aspiration, coma, malnutrition, prolonged
hospitalization, hypotension, and metabolic disorders. Hospitalized patients are also exposed to
potential bacteria from other sources (e.g., respiratory therapy devices and equipment, and
transmission of pathogens by the hands of health care personnel).

Community-Acquired Pneumonia

CAP, a common infectious disease, occurs either in the community setting or within the first 48 hours
after hospitalization or institutionalization. The need for hospitalization for CAP depends on the
severity of the pneumonia. The causative pathogens for CAP by site of care are shown in. The
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specific etiologic pathogen is identified in about 50% of cases. The overall rate of CAP in adults is
approximately 5.16 to 6.11 cases per 1000 persons per year; the rate of CAP increases with age
(Marrie, 2015). More than five million cases of CAP are reported each year, with the greatest
number in those 65 years and older (CDC, 2014a; Marrie, 2015).

 What is reverse isolation, quarantine and isolation?

 Reverse Isolation refers to the practice of healthcare workers and visitors wearing barriers (i.e.,,
gown, gloves, mask, etc.) routinely upon entry to the client room, for the purpose of preventing
client exposure to external microbes.
 Quarantine separates and restricts the movement of people who were exposed to a contagious
disease to see if they become sick.
 Isolation separates sick people with a contagious disease from people who are not sick.

 Differentiate bronchopneumonia and covid 19.

 The term bronchopneumonia is used to describe pneumonia that is distributed in a patchy
fashion, having originated in one or more localized areas within the bronchi and extending to the
adjacent surrounding lung parenchyma. Bronchopneumonia is more common than lobar
pneumonia
 COVID-19 is a respiratory disease caused by SARS-CoV-2, a new coronavirus discovered in
2019. The virus is thought to spread mainly from person to person through respiratory droplets
produced when an infected person coughs, sneezes, or talks. Some people who are infected may
not have symptoms. For people who have symptoms, illness can range from mild to severe.
Adults 65 years and older and people of any age with underlying medical conditions are at higher
risk for severe illness.

What are the different microorganisms that causes pneumonia?

Streptococcus pneumonia Haemophilus influenza

Staphylococcus aureus Moraxella catarrhalis

Group A Streptococcus Anaerobes

Klebsiella pneumonia gram-negative organisms.

 S. pneumoniae (pneumococcus) is the most common cause of CAP in people younger than 60
years without comorbidity and in those 60 years and older with comorbidity (Cunha, 2015;
Marrie, 2015). S. pneumoniae, a gram-positive organism that resides naturally in the upper
respiratory tract, colonizes the upper respiratory tract and can cause disseminated invasive
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infections, pneumonia and other lower respiratory tract infections, and upper respiratory tract
infections such as otitis media and rhinosinusitis.
 H. influenzae causes a type of CAP that frequently affects older adults and those with comorbid
illnesses (e.g., chronic obstructive pulmonary disease [COPD], alcoholism, and diabetes). The
presentation is indistinguishable from that of other forms of bacterial CAP and may be subacute,
with cough or low grade fever for weeks before diagnosis.
 The common organisms responsible for HAP include the Enterobacter species, Escherichia coli,
H. influenzae, Klebsiella species, Proteus, Serratia marcescens, Pseudomonas aeruginosa,
methicillin-sensitive or methicillin-resistant Staphylococcus aureus (MRSA), and S.
pneumoniae.