Question

Mr. B is a 63-year-old man who is clinically obese. He has a long history of chronic obstructive pulmonary disease (COPD) associated with smoking two packs of cigarettes a day for 40 days. During the past week, Mr. B has experienced a flu-like illness with fever, chills, malaise, anorexia, diarrhea, nausea, vomiting, and productive cough with thick, brownish, purulent sputum.

Clinical Assessment

Mr. B is admitted to the intermediate care unit from the emergency department with acute respiratory insufficiency. He is sitting up in bed, leaning forward, with his elbows resting on the over-the-bed table. Mr. B is breathing through his mouth, taking rapid shallow breaths, using his accessory muscles to ventilate. On inhalations, his nostrils flare and his accessory muscles retract. During exhalation, Mr. B uses pursed-lips breathing, and his intercostal muscles bulge. He appears anxious and irritable and is able to speak only one to tow barely audible words between each breath. Auscultation reveals crackles posteriorly over the right and left lower lung fields.

Diagnostic Procedures

His admission chest radiograph reveals infiltrates in the right lower lobe and left lower lobe. Gram stain of a sputum sample shows numerous gram-positive diploccoci. His baseline vital signs are as follows: Blood pressure of 110/60mm Hg. Heart rate of 108 beats/min (sinus tachycardia), respiratory rate of 30 breaths/min, temperature of 101.3 °F. His baseline arterial blood gas values on a 28% Venturi face mask are as follows: Pao2 of 58mmHg, Paco2 of 33mmHg, pH of 7.52, Hc03 level of 28, and oxygen saturation of 88%.

Medical Diagnosis

Mr. B is diagnosed with community-associated pneumococcal pneumonia

1. What major outcomes do you expect to achieve for this patient?
2. What problems or risk must be managed to achieve these outcomes?
3. What interventions must be initiated to monitor, prevent, manage or eliminate the problems and risks identified?
4. What interventions should be initiated to promote optimal functioning, safety, and well-being of the patient?
5. What possible learning needs do you anticipate for this patient?
6. What cultural and age-related factors may have a bearing on the patient’s plan of care?

Answer 1

major outcomes to expect:
-Respiratory failure and sepsis is high risk complication which is to be managed..
-poor gas exchange and heart problem
-Respiratory alkalosis
-ineffective airway clearance
-Altered neurological status.
-Pneumothorax
problem or risk must be managed:
- Infection should be under control..
- Flu symptoms should be managed
- His lifestyle pattern should be changed and mental ststus should be stable
- His lung secretion should be cleared and his position should be maintained
- Respiratory alkalosis should be compensated.
- fluid level should be maintained
Intervention to manage the risk factors:
- His lung infection should be managed with antibiotic therapy
- His lung secretion should be removed with nasotracheal suctioning, and encourage semi fowlers position to improve breathing pattern and lung expansion
- Encourage fulid upto 3L per day to loosen the secretion
-administer sodium bicarbonate as per doctor advice to balance the acid base level..
- Administer antipyretic as per doctor advice to control the fever
- oxygen therapy to support the breathing and lung expansion and hypoxemia
- check vitals every hourly
-monitor his mental status and encourage patient to express his fear..
-monitor ABG level every 6th hourly
- check serum electrolytes
- Follow strict aseptic technique to disposing sputum..
To promote optimal function ,safety,and well being:
- Follow aseptic technique while handling patient..
- Encourage patient coughing and deep breathing exercise..
-Teach patient about incentive spiro metry at home to expand the lung..
-advice patient about weight reduction and to follow high protein, high calorie diet with small frequent meals..
-Advice patient to improve his activity level day by day to loosen the secretion..
- Advice patient to stop cigerette smoking to avoid lung failure and damage..
- encourage family members to support patient in his activity level and his neurological status should be monitored..
- Advice patient to follow the medication with correct doses, interval..
-Advice patient to contact doctor if patient feel any abnormality..and strict followup should be done
- teach patient deep breathing exercise and coughing exercise and advice the patient to change his position often to loosen the secretion..