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

Questions

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

1. What major outcomes do you expect to achieve for this patient?

Achieve a respiratory rate near normal

Achieve a normal body temperature

Maintain normal BP

Maintain a normal blood pH

Improve oxygen saturation

Improved participation in daily activity

Maintain a normal body weight

Improve comfort

2. What problems or risk must be managed to achieve these outcomes?

Smoking cessation

Pneumonia control

Obesity management

Manage tachycardia

3. What interventions must be initiated to monitor, prevent, manage or eliminate the problems and risks identified?

Monitoring:

Vital signs

Pulse oximetry

ABG analysis

Assess the patient frequently

Prevention:

Flu vaccine

Tdap booster

Take COPD medicines properly

Improve the quality of life

Quit smoking

Well ventilated environment

Frequent checkups

Maintain normal weight

Management:

Antibiotics

COPD medications

Nutrition

Fluid therapy

Oxygen therapy

Airway clearance

Monitoring: ABG

Ambulation

ECG

Radiography

Checking vital signs

Elimination:

Medications

Well ventilated room

Avoid cross-contamination and infection

4. What interventions should be initiated to promote optimal functioning, safety, and well-being of the patient?

Frequent monitoring

Assistive devices

Meeting daily needs

Nutrition

Oxygen therapy

Medications

Weight reduction

5. What possible learning needs do you anticipate for this patient?

Importance of smoking cessation

Avoidance of infection chances

Medication administration

Positioning to minimize the laboured breathing

Maintenance of pulmonary hygiene

Symptoms of complications

6. What cultural and age-related factors may have a bearing on the patient’s plan of care?

Care of old age

Care of the patient with COPD and CAP (community-acquired pneumonia)

Communication without much disturbing the patient as he is not able to speak properly

Calm and quiet environment to minimize stimuli