Case study 1 – Jonah Roberts.
Jonah Roberts is a 78-year-old man who attended A and E with a productive cough. He was breathless with a respiratory rate of 32 breaths per minute and a temperature of 38.9°C. He was with his wife whom is relatively frail and uses a walking stick. She needs help with certain activities of daily living due to scoliosis of the spine and osteoporosis. He has no children but their nephew lives nearby and will help with jobs in the house and running errands. He is relatively healthy and usually attends a working men’s club in the evening for a chat and pint of lager. Jonah has had problems with his blood pressure and has been taking 5mg Felodipine once a day to control this.
An x-ray was undertaken and an initial diagnosis of community acquired pneumonia was made. He had consolidation on his right lung and was hypoxic on room air of 82%. Oxygen was administered at 15litres whilst awaiting review from critical care outreach. His saturations on oxygen were 92% and he was tachycardic. He had bloods taken including urea and electrolytes (U&E’s), Full blood count (FBC) and blood and sputum cultures.
His last set of Observations were:
- Blood pressure 105/64mm/Hg
- Pulse 121 beats/min
- Temp 38.9°C
- Sats 92% on 15Litres of Oxygen
- Pain score is 6/10
- Respiratory rate is 32 breaths/minute
- Blood sugar 6.7mmol
- Capillary refill time 4 seconds
Jonah was extremely breathless and was unable to speak due to effort undertaken to breath. His lips were dry and cracked and his pallor was pale. He complained of being cold and requested blankets to keep warm. His temperature was still elevated. He had pain in his chest as a result of the infection and he was given 1gram of paracetamol IV.
He was given Amoxicillin 500mg every 8hours IV and had his observations were to be taken every hour. Jonah was very tired and weak but was orientated to time and place.
Case study
Case Scenario Analysis essay (3000 words) which explores the fundamental elements of care for the acutely ill adult (60%).
As part of the case study analysis include discussion covering the following two aspects:
Part a)
Critically discuss the relationship between the signs and symptoms and the final diagnosis, taking into account the aetiology, disease process, lifestyle and psychosocial aspects that may influence his/her behaviour.
Part b)
Using evidence based literature critically explore the management of the patient. Taking into consideration key nursing assessments and interventions that would ensure best practice.
Within these sections it is expected you will include discussion on pathophysiology of the disease and link this to observations or blood results. Medications should be discussed and their relationship to evidence based practice or their relevance to disease.
Consider appropriate assessments and explore these in depth. Linking these into the case study and actual or proposed interventions. Consider psychosocial aspects and their impact on the patient.
Community Acquired Pneumonia
Cast Study Solution
Part A
Upon analysis, examination as well as the chest x-ray analysis of the patient clearly depicted that the patient suffers from community acquired pneumonia (CAP). According to the definition provided by Watkins & Lemonovich (2011), CAP is an infection of the lung parenchyma that is not acquired in the hospitals, nor the long-term care facilities nor any other contact with a healthcare system. This illness is considered among the most important types of lung infections in the world. According to Torres, Peetermans, Viegi & Blasi (2013), the annual incidence rate of CAP in the United States of America alone is between 5 and 11 cases per 1000 adults and more than 20 cases in adults above the age of 65 years.
Apart from these main tests, there are other several reasons why pneumonia is the most likely condition affecting this patient. First is the age of the patient. According to the case study, the patient, Jonah Robert, is 78 years old. Research has clearly demonstrated that the elderly persons are at a higher risk of community acquired pneumonia in comparison to the younger population (Fimognari et al., 2016). Research has shown that the rate of community acquired pneumonia is higher among the elderly and that the short term prognosis of the disease may be poor as a result of the comorbid diseases and illnesses which contribute to death.
The second risk factor of CAP that the patient is exposed to is the use alcohol. According to the study by Kershaw & Guidot (2008), alcoholism has long been recognized as an important risk factor of pneumonia. There are a number of reasons why alcohol is a typical risk factor of pneumonia. The main once however are the increase in the risk of aspiration of gastric acid and microbes from the upper sections of the throat, decreased mucous-facilitated removal and cleaning of bacteria pathogens from the airways as well as impaired and decreased defense of the pulmonary host from the bacteria (Kershaw & Guidot, 2008).
The third primary risk factor of pneumonia that the patient is exposed to is living with his wife who is affected by scoliosis of the spine and osteoporosis. Scoliosis is one of the primary causes of aspiration pneumonia. Although patients of scoliosis may or may not experience swallowing difficulties, this symptom may arise and may become severe if untreated. This occurs when nerve damages weaken the muscles and thus hinder the ability of the body to control the muscles that are involved in swallowing. When proper swallowing is disrupted, it may result in foods and drinks being inhaled into the lungs and thus posing a significant risk of aspiration pneumonia (Pietrangelo, 2013). Coughing is the most immediate result of aspiration pneumonia. Exposure of an individual to contaminated air from the patients of aspiration pneumonia also increases the risk of helpers to either aspiration or other forms of pneumonia.
Community acquired pneumonia develops when the defense mechanisms of the lungs are overwhelmed by pathogens which are either inhaled or aspired into the body. Although there are various CAP-causing organisms, the main one is Streptococcus pneumonia, a gram-positive α-haemolytic capsulated organism (Morgan & Glossop, 2016). The risk of infection by this organism is especially higher among adults as compared to the young people (Morgan & Glossop, 2016). The signs and symptoms of this disease are primarily the results of the effects of the causal organisms on the lungs and the neighboring tissues. In understanding the effects of the Streptococcus pneumonia and the relationship between the disease and the main signs and symptoms, it is particularly essential to assess the stages of development of CAP.
CAP develops in four main stages. The first stage is the congestion stage. This stage represents the early acute inflammatory response of the alveoli in the lungs. At this stage, the affected alveoli becomes red and heavy as a result of vascular congestion. The stage lasts for approximately 24 hours to 48 hours during which the affected alveoli are filled with oedema fluid and bacteria. During this stage, the copious proteinaceous fluid, abundant neutrophils and bacteria can easily be seen from in the lungs either through the use of x-ray graphics. The cellular exudates that contain neutrophils, lymphocytes and fibrin replace the alveoli air while the capillaries surrounding the affected alveoli walls are congested leading to an increased pulse rate as the heart attempts to push more blood through these capillaries. Pleurisy is often at this stage leading to the patients feeling painful while breathing. At the same time, the number of breaths per minute are also expected to increase, as observed in the case study patient, due to the insufficiency of oxygen in the lungs. According to the case study, Jonah’s rate of breathing increased from the normal 12 – 20 breaths per minute to as high as 32 breaths per minute. According to Atkuri & King (2006), this phase is market by coughing and deep breathing.
The second stage in the development of CAP is the red hepatisation stage. This is the stage that immediately follows the congestion stage. The stage lasts for between 2 to 4 days and is primarily characterized by the reddening of the affected lobes. The lobes, as a result of the increasing amount of fluid in them, becomes firm and takes the consistency of the liver (Lutfiyya, Henley, Chang & Reyburn, 2006). The extravasation of the red cells gives the lungs a red color. At this stage, the lungs of the patient becomes hypeaemic, the capillaries of the alveolar are engorged with blood and the exudates of the fibrin fills up the alveoli. According to Atkuri & King (2006) and Steyl (2007), this stage is primarily characterized by the presence of many erythrocytes, neutrophils, fibrin and desquamated epithelial cells in the alveoli.
The patients depict difficulty and feels pain when breathing, pulse increases and the respiratory rate is also observed to increase above the normal rate of respiration. Since the capillaries are engorged with blood, the capillary refill rate may also be observed to increase above the normal refill time as observed in the patient. At this stage, the congestion within the capillaries as well as the alveoli may be expected to significantly increase the blood pressure within the lungs and a slight increase in the body temperature above the normal range.
The third stage is the stage of gray hepatisation. This stage is characterized primarily be the drying of the affected lobes. The affected lobes also become firm and appear gray as a result of the lysed red cells. The exudates from the Neutrophilic cellular may also be observed to consistently decline as a result of the breakdown of the inflammatory cells. Macrophages may be observed at this stage. The load of the microorganisms may also be observed to reduce at this stage. At this stage, the pressure resulting from the exudates within the alveoli results in a significant compression of the capillaries thus increased blood pressure, temperature and the rate of respiration above the normal ratings. The compression of the capillaries also results in a significant increase in the refill time of the capillaries. Atkuri & King (2006) explains that the leukocytes also migrate into the congested alveoli at this stage.
The final stage is the resolution stage. As a result of the increasing enzymatic actions within the alveoli, the fibrinous matter in the alveoli is liquefied and the aeration of the lungs is re-established. According to Atkuri & King (2006), the stage is primarily characterized by the re-sorption and the restoration of the pulmonary architecture. At this stage, a considerable amount of the macrophages enter the alveoli spaces and the phagocytosis of the leukocytes that are laden by bacteria occur (Steyl, 2007). There is progressive reduction of fluid and the cellular exudates from the alveoli through the processes of expectoration as well as lymphatic drainage. This leads in a normal parenchyma of the lungs within a period of 3 weeks.
The assessment and the description provided above clearly denotes that the patient is in the first stage of pneumonia development. According to the case study, the patient was healthy and usually attended the working men’s club in the evening for chats. This clearly demonstrates that the pneumonia causing bacteria may not have been in the lungs for more than a day since the signs and symptoms of the disease are mostly visible after approximately 24 hours after acquiring the bacteria. More importantly, most of the above mentioned characteristics and attributes of the first phase of the disease are depicted clearly in the signs and symptoms that the patient depicts. As a result of the firms becoming firm, the patient is expected to feel pain while breathing as the muscles of the lungs rub along the other bordering tissues and cells of the body. He feels cold as a result of elevated temperatures of the body which usually leads to a significant increase in the rate of evaporation from the skin thus his feeling cold.
Part B
Proper management of patients in the hospital environment plays an important role in determining the recovery of the patients. As such, establishing a proper management plan for pneumonia patients is one of the most important and critical steps in ensuring success of the treatment option (File, Bartlett & Thorner, 2016).
In severely affected patients, a pre-requisite to treatment is the prescription of oxygen. The oxygen saturation of the patients administered in the A&E department should be conducted in order to assess whether the patient under consideration has enough or sufficient oxygen to sustain life. Oxygen saturation on both air and oxygen should be assessed to assist in establishing this decision. Based on these two assessments, the physiotherapist should prescribe oxygen as appropriate (Callus, Micallef, Mamo & Montefort, 2012). As was observed in the case of Jonah, there exists considerably low saturation of oxygen in the blood thus calling for immediate application of oxygen. This will play an important role in ensuring the circulation of air within the body and reduce the progress and the continued severity of the disease.
The first and perhaps the most important decision is the determination of whether the patient should be treated as an outpatient or requires hospitalization. As was explained in part a above, there are many bacteria that may lead to the community acquired pneumonia. As such, before the beginning of any type of treatment, it is essential that the physicians begin by assessing the actual cause of the disease. The severity of the condition is the most important factor when making this decision. However, it is important and essential to also consider other factors including the ability of the patient to maintain oral intake, the likelihood of the patient’s compliance, history of substance abuse, the situation of living, and cognitive impairment of the patient and the functional status of the patient (File, Bartlett & Thorner, 2016).
In the establishment of this decision, there are a number of tools that have been to assist in this decision. The main ones include the pneumonia severity index (PSI) and the CURB-65. Although the PCI has extensively been studied, it requires complex assessments and thus not common among doctors and nurses. CURB-65 is as such considered better and more suitable for use. According to File, Bartlett & Thorner (2016), the CURB-65 assessment tool use five main prognostic variables including confusion, urea, and rate of respiration, blood pressure and age. Based on the above criteria, Jonah’s signs and symptoms and CURB-65 assessment shows that he should be hospitalized.
As earlier explained, there exists a wide range of organisms that may cause CAP. As a result of this and the challenge in the identification of the actual causative agent of the disease (Mandell, Wunderink & Anzueto, 2007), empirical therapy is conducted. Although presentation features and chest radiography plays an important role in the identification of the disease, they are not sufficient to determine the etiology of the disease nor to influence the treatment decisions. The gram stain of the respiratory secretions can be particularly useful in this stage if it is performed using a good quality sputum and done by a skilled examiner (Mandell, Wunderink & Anzueto, 2007). This also influences the type of medication applied owing to the observed resistance of patients to particular drugs.
After the identification of the causative agent, the next step in the management and treatment of CAP is pharmacotherapy. The primary objectives and goals of this step is to eradicate the causative agent, resolve the signs and the symptoms depicted by the patient, minimize the hospitalization and the days of hospitalization of the patient and prevent re-infection (Lutfiyya, Henley, Chang & Reyburn, 2006). The type of medication applied by the physician should primarily be dependent on the pharmacokinetic profile, the expected adverse effects of the medication, the interaction of the drug with the patient and cost-effectiveness of the particular drug selected (Lutfiyya, Henley, Chang & Reyburn, 2006).
Although most adult patients are treated empirically primarily based on the most common pathogens associated with the disease, this may not be effective or efficient as it may be required. In the realization of the impacts and the high mortality rate resulting from CAP, a number of guidelines and procedures has been established by major health management bodies towards the treatment and proper management of the disease. The antibiotic regimen advocate which was developed by a collaboration between the infectious disease society of America and the American Thoracic Society in the year 2007 is one of the most important and applied guideline today. The British Thoracic Society has also been on the first line in the development of guidelines for the management of CAP among adults (Lutfiyya, Henley, Chang & Reyburn, 2006).
According to the guidelines established by the ATS, the infectious diseases society of America, the Canadian guidelines for the initial management of CAP recommends that the physicians first conduct an empirical therapy through the use of macrolides, fluoroquinolones, or doxycycline. The guideline developed by therapeutic Working Group of the CDC, however, recommends that the physicians should make use of fluoroquinolones during the empirical therapy, but advices that this should be used minimally due to the concerns on resistance of the pathogens (Lutfiyya, Henley, Chang & Reyburn, 2006). With the consideration that none of these concerns exist in consideration Jonah, empirical treatment may first be applied to the patient.
Although there exists a considerable limited amount of literature on the management of CAP, most of the existing works of research recommend therapy of between seven and 10 days in instances when the causative agent is S. pneumonia and between 10 to 14 days therapy when dealing with Mycoplasma pneumoniae and Chlamydia pneumonia. After the hospitalized patient is clinically stable, i.e the body temperature of 37.8o, pulse under 100 beats per minute, the rate of respiration below 24 breaths per minute and the systolic pressure above 90mmhg and a blood oxygen saturation of approximately 90% and be in a position to adequately tolerate intake of oral medication, then the physician can adopt the use of oral medications for the treatment of the condition. This allows for cost-effective treatment and management of CAP while at the same time allowing the discharge of the patient earlier than other approaches and plays an important role in minimizing the risk of the patient to hospital acquired pneumonia (Lutfiyya, Henley, Chang & Reyburn, 2006).
Different guidelines have supported the use of different forms of medications. For the patients who are hospitalized following adverse effects of the community acquired pneumonia, the guidelines by the IDSA/ATS recommends the use of antipneumococcal fluoroquinolone or the combination of beta-lactam and a macrolide. For the patients who are severely affected by the disease and who are admitted to the intensive care unit, the IDSA/ATS recommends the use of beta-lactam and either an intravenous azithromycin or an antipneumococcal fluoroquinolones. This are applied however unless there are concerns for the pseudomonas or the methicillin-resistant S. aureus (MRSA) infection. If these concerns exist, the ATS recommends the use of an anti- pseudomonal agent added to an antipseudomonal fluoroquinolones. In cases where the MRSA is a concern, vancomycin or linezolid should be added to the treatment medication.
With the use of proper forms of medication and treatment, the results of the therapy are expected in between 48 and 72 hours after the initiation of the treatment. All patients who do not demonstrate any changes in their health and response within this period of time should be considered as non-responders and as such different forms of medication should be considered. Most of the non-responders are often affected by other types of causative agents other than the normal bacteria and as such required a different format of treatment, other than the use of the already recommended antibiotics.
It is however important to note that although the response of the patients to drugs and antibiotics may be observed within just a few days after the initiation of the treatment, the resolution usually may take a considerable number of days. Pneumonia leads to considerable damages of the lungs and the affected alveoli and as such may take time to heal and the patient to recover from the condition. The time for the complete resolution of the signs and symptoms and the resolution of the results obtained from the radiography may take a considerable amount of time. According to Lutfiyya, Henley, Chang & Reyburn (2006), cough in pneumococcal pneumonia mainly resolves after a period of approximately eight days while the auscultatory crackles often clear within a period of three weeks.
Research has also demonstrated that in many patients, approximately 87%, there exists one prolonged symptom that is related to CAP as compared to the signs and symptoms observed during the onset of the disease (Lutfiyya, Henley, Chang & Reyburn, 2006). Signs such as fatigue, cough without the production of sputum, dyspnea and pain in the chest may persist for as long as approximately 30 days after the disappearance of the other signs and symptoms. With this understanding, it is imperative that patients are notified of the expectation of persistence in some of the symptoms in order for them to be able to set up reasonable expectations for their course of treatment.
References;
- Atkuri, V., & King, R. (2006). Pediatrics, Pneumonia. Retrieved 7th Dec 2017, from https://emedicine.medscape.com/article/803364-overview
- Callus, R., Micallef, J., Mamo, J. & Montefort, S. (2012). Concordance Study: Hospital management of community-acquired pneumonia in Malta. Malta Medical Journal, 24(2), 6 – 11.
- File, T., Bartlett, J. & Thorner, A. (2017). Treatment of community-acquired pneumonia in adults who require hospitalization. Retrieved 7th Dec 2017, from https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&ved=0ahUKEwjs4JzhyvfXAhWDuRQKHZB6CJ0QFggxMAI&url=https%3A%2F%2Fwww.uptodate.com%2Fcontents%2Ftreatment-of-community-acquired-pneumonia-in-adults-who-require-hospitalization&usg=AOvVaw0QIxm6Fu38sxutPDDFdraR
- Fimognari, F., Corsonello, A., Pilotto, A., Rizzo, M., Bambara, V., Cristiano, G., Ferrari, A. et al. (2016). Community acquired pneumonia in the elderly: the Pneumonia in Italian Acute Care for Elderly units (PIACE) study protocol by the Italian Society of Hospital and Community Geriatrics (SIGOT). Geriatric Care, 2(6569), 60 – 66.
- Kershaw, C. & Guidot, D. (2008). Putting systems biology approaches into practice. Alcoholic lung disease. Alcohol Research & Health, 31(1), 66 – 76.
- Mandell, A., Wunderink, G., Anzueto, A., et al. (2007). Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis, 44(2), S27.
- Pietrangelo, A. (2013). Multiple sclerosis from top to bottom: getting the complete picture. Retrieved 7th Dec 2017, from https://www.healthline.com/health/multiple-sclerosis/effects-on-the-body
- Steyl, T. (2007). Applied Physiotherapy 403 notes: Intensive Care Notes. University of the Western Cape.
- Torres, A., Peetermans, W., Viegi, G. & Blasi, F. (2013). Risk factors for community-acquired pneumonia in adults in Europe: a literature review. Thorax, 68(1), 1057 – 1065.
- Watkins, R. & Lemonovich, T. (2011). Diagnosis and Management of Community-Acquired Pneumonia in Adults. American Family Physician, 83(11), 1299 – 1307.