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Mr. Edward Hunter, an 89-year old widower, was admitted to your medical ward with hypoxaemia (oxygen saturations 82% in the ambulance) and a recent history of viral influenza. He has been receiving intensive home support from the 'acute care in the home' nursing team for over 6 months, which includes home oxygen therapy as his chronic obstructive airways disease worsens limiting his ability to care for himself at home. 
Within 20 hours of admission Mr. Hunter's condition continues to deteriorate. He is receiving 10 liters of oxygen via a Hudson mask. Severe dyspnoea renders him immobile and barely able to eat. He has little appetite and is cachexic. Overnight night he becomes quite restless, breathless, tachypnoeic and develops a productive cough. The respiratory team reviews Mr. Hunter because he was experiencing increased pleuritic pain on inspiration and was expectorating rust colored sputum. Subsequently, he was diagnosed with pneumococcal pneumonia and was prescribed cough suppressant, a sedative and antibiotics. 


1. Mr. Hunter is 89 years old. What ore the specific considerations a Registered Nurse should understand in relation to the clinical manifestations of pneumonia in the older person? 

2. Outline the pathophysiology of altered ventilation and diffusion in relation to Mr. Hunter's pneumonia.

Yesterday evening, in handover to the night duty nurse, it was explained that Mr. Hun was becoming confused and drowsy during the day but was easily roused and oriental once woken and maintaining oxygen saturations 92 .94%. 
Mr. Hunter is clearly distressed and extremely dyspnoeic. The consultant reviews Mr. Hunters medication and prescribes Oxygen (high flow) to achieve oxygen saturation > 92% Benryl penicillin 1.2g IV 6 hourly for a total of 7 days Process information 
Interpreting information can be difficult if you process it subjectively based on your ox past experiences, beliefs and opinions. By critically appraising the information about IP various types of pneumonia, it is possible to make a reasoned judgment about Mr. Hur future management. 

3. Whot ore the differences between hospital acquired pneumonia (HAP, community acquired pneumonia (CAP)and aspiration pneumonia? 

 The consultant also requests that Mr. Hunter has 4 hourly observations of his vi signs and to report a heart rate above 100 and oxygen saturations below 90% and a temperature above 38.5c. 

Take action 

The registered nurse recognises that Mr. Hunter requires care beyond that requested t consultant. 

4. explain the nursing core required the patient with pneumonia. Provide o rationale for all elements of the core provided that reflects the particular needs of Mr. Hunter. 

Hypoxemia in the Elderly

Pneumonia is a disease caused by infections of the lungs as a result of bacterial or viral attacks. It causes a consolidation and collapse of the lungs thus interfering with respiration in patients. Anyone is at risk of suffering from pneumonia but the elderly and young children are more susceptible to this disease due to a weaker immune system (Ruuskanen et a., 2011, p. 1266). The symptoms of pneumonia among the elderly depend on their overall health and functional status. In the case study provided, we are told of the condition of Mr. Hunter who is an 89-year old man. There are specific considerations that a registered nurse must understand regarding the clinical manifestations of pneumonia among the elderly like in Mr. Hunter’s case. Below, we will discuss some of these considerations.

It is important to note that the lungs and the nerves that connect to the lungs among the elderly are not always very reactive and responsive. The lungs are therefore weak and less sensitive thus making them more susceptible to pneumonia (Saguil and Fargo, 2012, p. 355). From the scenario presented, we are informed that Mr. Hunter has developed hypoxemia. The compliance of the chest wall progressively reduces as one gets older. The airway may start closing at small volumes due to a loss of the supporting tissues that surround the airways. As a result, the patient suffers a progressive decline in the volume of saturation of oxygen which may cause hypoxemia.

It is also important to note that aging causes the inflexibility of the lungs thus leading to a collapse of the air sacks responsible for oxygenation. This is especially more common among the elderly suffering from pneumonia, as is the case of Mr. Hunter (Sue Eisenstadt, 2010, p. 18). The result is a development of a shortness of breath a condition known as dyspnea. Additionally, the elderly like the patient in our scenario have increased morbidity and mortality. This combined with his condition of pneumonia increases the risks of developing cachexia which can be described as unintentionally losing weight (Marrie, Bartlett and Thorner, 2013). Furthermore, due to the worsening situation of his chronic obstructive airways disease, he develops tachypnea as the body attempts to compensate for the low oxygen concentration that is said to be only 82%. The pleuritic pain that he develops is as a result of deep breathing and coughing. Due to the infection of the lungs as a result of pneumonia, his sputum becomes purulent which can be characterized by a color similar to rust.  

Pneumococcal pneumonia is a major cause of respiratory failure among the elderly thus causing several deaths if the situation is not addressed. The respiratory failure exists in two forms that are the ventilatory failure and hypoxemic respiratory failure. The mechanical changes of the lungs due to pneumonia are the major causes of ventilatory failure. An inflammatory reaction normally takes place in the alveoli thus producing an exudate that fills alveoli (Wagner and West, 2012, p. 219). This filling, however, happens at a functional residual capacity that is slightly less than normal thus leading to a reduction in the volume of functional residual capacity. As a result, the total lung compliance is reduced and the work of breathing is increased hence interfering with ventilation and diffusion (West, 2012, p. 73). Additionally, the white blood cells migrate and fill the alveoli.

Mechanical Changes of Lungs in the Elderly

Studies have further revealed that secretions and mucosal edema associated with pneumococcal pneumonia cause a partial occlusion of the alveoli and bronchi and thus the areas of the lungs are not adequately ventilated. The result is that the oxygen tension of the alveoli is reduced. This further reduces the dynamic compliance of the remaining ventilated lung which thus increases the work of breathing as shown by Mr. Hunter’s low saturation of oxygen. Additionally, the patient becomes breathless and tachypneic accompanied with an increase in the pleuritic pain during inspiration.

A mismatch between ventilation and perfusion during the later stages of pneumococcal pneumonia causes hypoxemia as is evidenced by the scenario provided in our case study. The perfusion-ventilation mismatch occurs due to hypoventilation in the affected areas of the lungs (Petersson and Glenny, 2014). As a result, the venous blood that enters into the pulmonary circulation travels through the area of the lung that is under-ventilated and comes out poorly oxygenated via the left side of the heart. This mixing that occurs between oxygenated and poorly oxygenated blood eventually lead to hypoxemia (Petersson and Glenny, 2014). Another factor that causes hypoxemia in pneumococcal pneumonia is the persistent pulmonary blood flow to the consolidated lung. This persistence in the flow results from the failure of the mechanism of hypoxic pulmonary vasoconstriction. This, according to Hough (2013), affects the diffusion of oxygen from the alveoli to the blood (p. 8).

Hospital-Acquired Pneumonia

A patient develops hospital-acquired pneumonia within 48 hours of admission to the hospital. It is mostly caused by micro-aspiration of bacteria that attack the upper airways in the critically ill patients. It can also be caused by inhalation of aerosols that contain influenza virus or Aspergillus sp (Barbier et al., 2013, p. 217). Overall, the greatest risk factor for hospital-associated pneumonia is an endotracheal intubation that is combined with mechanical ventilation. This is because the endotracheal intubation interferes with the airways prejudices mucociliary clearance and cough, and encourages the micro-aspiration of the secretions full of bacteria that are located above the endotracheal tube cuff that is normally inflated. According to Victor (2011), this type of pneumonia is characterized by chest pains, dyspnea, cough, fever, malaise, increased respiratory rate and heart rate, increased purulent secretions, and hypoxemia (p. 250).

Community-Acquired Pneumonia

Community-acquired pneumonia, on the other hand, develops among individuals who have limited or no contact with medical institutions. The common causative agents of this condition are Haemophilus influenzae and Streptococcus pneumoniae. There are several organisms that cause community-acquired bacteria, ranging from bacteria, fungi, and viruses (Marti and Esperatti, 2016, p. 116). The symptoms of this infection include malaise, fever, dyspnea, chest pains, cough, and chills among others. The cough is normally productive in the elderly patients as is the case with Mr. Hunter. The chest pain is normally pleuritic that is adjacent to the infected area. The signs of community-acquired pneumonia include crackles, tachycardia, tachypnea, fever, and bronchial breath sounds among others (Marrie, Bartlett and Thorner, 2013). The treatment of this condition is based on empirically chosen antibiotics.

Types of Pneumonia

Aspiration pneumonia results from an inhalation of toxic substances that include gastric contents into the lungs. It thus causes an inflammation of the lungs, a condition known as chemical pneumonitis, lung abscess, or airway obstruction (Sue Eisenstadt, 2010, p. 20). The risk factors for aspiration pneumonia may include dental procedures, gastro-esophageal reflux disease, impaired swallowing, nasogastric tube placement, and endotracheal intubation among others. The signs and symptoms of aspiration pneumonia include a cough, fever, dyspnea, and chest pains. Treatment normally involves a combination of antibiotics, supplementary oxygen, and mechanical ventilation (Ebihara, Ebihara and Kohzuki, 2012, p. 30). It is advisable to optimize dental hygiene to help in preventing the development of aspiration pneumonia.

Nursing care plans for patients suffering from pneumonia consist of supportive measures such as oxygen therapy that is humidified to manage hypoxemia. Additionally, there is always a form of mechanical ventilation to treat respiratory failure. Furthermore, a care plan involving a fluid intake and a high-calorie diet could also be initiated. Below, we will discuss some of the nursing care plans to help in caring for Mr. Hunter.

Ineffective airway clearance could be described as the inability of the patient to clear obstructions such as secretion from the respiratory tract to maintain a clear airway. This condition could be related to pleuritic pain that is experienced by Mr. Hunter. Additionally, it is related to an increase in the production of sputum. It could be characterized by a change in respiratory rates, dyspnea, and coughs among others. The interventions for this care are normally aimed at displaying patent airways with the absence of dyspnea.

The following are some of the interventions that could be employed to achieve the above-mentioned aims. Firstly, Mr. Hunter’s bed should be elevated and the nurse should frequently change the patient’s position. This intervention helps to lower the diaphragm and enhance the expansion of the chest and the aeration of the lungs and as a result, expectorate secretions. Secondly, it would be important to auscultate the lung fields. This is done to identify areas with an absence of airflow and to detect adventitious breathing (Gulanick and Myers, 2011, p. 431). It is important to note that a decrease in the airflow occurs in the areas that contain consolidated fluids. The crackles and wheezes are also heard due to an accumulation of fluids, airway obstructions, and thick secretions.

Managing Acute Pain

Acute pain may be related to persistent coughing and a possible inflammation of the lung parenchyma. Some of its characteristics such as restlessness and pleuritic chest pains are exhibited by Mr. Hunter. The first intervention to this condition could be an assessment of the characteristics of the pain. The nurse investigates the changes in pain location and its intensity. It is important to note that chest pains in some instances herald the onset of pneumonia associated complications. Secondly, it is important to offer the patient oral hygiene on a frequent basis. This is due to the fact that an oxygen therapy and mouth breathing aid in drying out the mucous membranes thus causing potential discomforts (Dunphy et al., 2015, p. 457). Additionally, the nurse could instruct the patient on techniques of splinting the chest during coughs. This helps in controlling the discomfort of the chest while enhancing effective coughing at the same time.

Hospital-Associated Pneumonia

Managing Impaired Gas Exchange

This could be described as a deficit or excess oxygenation and elimination of carbon (IV) oxide between the capillary and alveoli. As exhibited by Mr. Hunter, this condition is characterized by dyspnea, hypoxemia, restlessness, and tachycardia. The nurse could apply the following interventions to help in addressing this issue. Firstly, the nurse could monitor the patient’s heart rate. Tachycardia, which is an increase in heart rate, is normally present due to fever and dehydration. It could also result from the condition of hypoxemia (Doenges, Moorhouse and Murr, 2016, p. 61). The aim, therefore, is to ensure that the heart rate does not exceed 100 beats per minute. Secondly, it is important to monitor the body temperature to help in reducing fevers and chills. The temperature, as indicated in the case study should not exceed 38.5 degrees Celsius. This is because high fevers usually increase the consumption of oxygen and the metabolic demands thus altering cellular oxygenation (Dunphy et al., 2015, p. 375). Thirdly, the administration of oxygen therapy is important to maintain the saturation of oxygen above 90% as highlighted in the case study. The oxygen is administered cautiously using the appropriate means, which in most cases is normally the Hudson mask.

It is greatly important to monitor Hunter’s heart rate to ensure that it does not exceed 100 beats per minute. It is important to note that pneumonia could lead to a possible condition of hypoxemia which may further result in tachycardia. Additionally, pneumonia could possibly push the heart into abnormal rhythms such as atrial tachycardia due to the dilation of the blood vessels located in the right side of the heart thus throwing off the heart’s electrical system (Hess, 2011, p. 523). If the patient’s heart rate is therefore not monitored, they could develop tachycardia which could disrupt the normal operation of the heart and lead to a sudden cardiac arrest, heart failure, stroke or a possible death at worst.

It is additionally important to monitor the level of saturation of oxygen and ensure that it does not fall below 90%. The aim is to ensure that the saturation of oxygen does not fall too low so as to help in managing hypoxemia. Saturation of oxygen below 90% could be an indication of hypoxemia and respiratory failure (LeMone et al., 2015, p. 1255). A high flow oxygen therapy is thus necessary to ensure that the saturation of oxygen is more than 92 which is considered normal.

Finally, the consultant recommends that Mr. Hunter’s temperature should be maintained at 38.5 degrees Celsius. Monitoring the body temperature helps in reducing fever and chills thus enhancing comfort. This is because high fevers that are commonly experienced in bacterial pneumonia and influenza which we are also informed that Mr. Hunter has a history of, massively increases the metabolic demands of the body. It is also important to note that fevers increase the consumption of oxygen and as a result, alter the cellular oxygenation.

Strategies

As a registered nurse, it is imperative to convince Mr. Hunter that he needs the oxygen therapy to help in maintaining his level of saturation of oxygen within the normal range. In the presented scenario, we are informed that the patient became agitated and requests that the oxygen therapy is stopped. Legally, the patient has the right to refuse any form of medication but the nurse has an ethical responsibility to make the patient understand the importance of any form of medication to their health (Jones, Shaban and Creedy, 2015, p. 192). The registered nurse could thus use some strategies to try and convince Mr. Hunter that refusing oxygen could have several implications.

Community-Acquired Pneumonia

Firstly, the nurse could actively engage Mr. Hunter in a conversation and the overall decision-making process regarding his health. This strategy will make the patient feel more involved in the medical processes that are aimed at addressing his condition. As a result, the quality of health may be improved if the patient sees the sense in changing his mind and once again accepting the oxygen therapy (Cashin et al., 2017, p. 260). Secondly, the nurse could decide to involve the family of Mr. Hunter to try and talk him out of his decision. It is understandable that an individual feels more connected to their families and therefore it could be easier to have a family member talk to Mr. Hunter about the possible implications of refusing oxygen.

As the registered nurse tasked with caring for Mr. Hunter, I would endorse a social support mechanism and family involvement. Involving the family of the patient would be crucial in improving oxygen adherence. A social support mechanism also encourages compliance with oxygen therapy. I would additionally propose a switch to a more convenient source of oxygen that is maybe portable as the patient could possibly be tired of having to lie down on bed day and night. This type of source of oxygen enables the patients to be independent and ambulatory. Furthermore, I would encourage frequent patient-doctor communication that is sincere to improve the adherence to oxygen therapy.

From the scenario presented in Mr. Hunter’s case study, I have been able to learn two important things. The first is that critically ill patients are at a great risk of deteriorating if their health conditions are not addressed promptly with the most appropriate interventions. Secondly, a patient has every right to refuse any form of medication and they, therefore, control their own treatment (Brown et al., 2017, p. 89). In my future practice as a registered nurse, I would always ensure that I prioritize the safety and well-being of all my patients. Therefore, I will always act as soon as possible to care for patients and prevent the deterioration of their health conditions. Additionally, since my number one priority as a nurse is to improve the quality of health and ensure patient safety, I will always try my best to make the patients understand the importance of any form of medication and the implications associated with refusing medication.

One of the NMBA nursing standards that relate to what I learned, in this case, is; provide safe, appropriate and responsive quality nursing practice. This will help in changing my practice several ways that may include practicing within my scope, appropriate delegation of aspects of practice to enrolled nurses, and practice in accordance to the relevant rules, regulations, standards, and practices.

References

Barbier, F., Andremont, A., Wolff, M. and Bouadma, L., 2013. Hospital-acquired pneumonia and ventilator-associated pneumonia: recent advances in epidemiology and management. Current opinion in pulmonary medicine, 19(3), pp.216-228.

Brown, D., Edwards, H., Seaton, L. and Buckley, T., 2017. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.

Cashin, A., Heartfield, M., Bryce, J., Devey, L., Buckley, T., Cox, D., Kerdo, E., Kelly, J., Thoms, D. and Fisher, M., 2017. Standards for practice for registered nurses in Australia. Collegian, 24(3), pp.255-266.

Doenges, M.E., Moorhouse, M.F. and Murr, A.C., 2016. Nursing diagnosis manual: Planning, individualizing, and documenting client care. FA Davis.

Dunphy, L.M., Winland-Brown, J., Porter, B. and Thomas, D., 2015. Primary care: Art and science of advanced practice nursing. FA Davis.

Ebihara, S., Ebihara, T. and Kohzuki, M., 2012. Effect of aging on cough and swallowing reflexes: implications for preventing aspiration pneumonia. Lung, 190(1), pp.29-33.

Gulanick, M. and Myers, J.L., 2011. Nursing care plans: Diagnoses, interventions, and outcomes. Elsevier Health Sciences.

Hess, D., 2011. Respiratory care: principles and practice. Jones & Bartlett Learning.

Hough, A., 2013. Physiotherapy in respiratory care: a problem-solving approach to respiratory and cardiac management. Springer.

Jones, T., Shaban, R.Z. and Creedy, D.K., 2015. Practice standards for emergency nursing: an international review. Australasian Emergency Nursing Journal, 18(4), pp.190-203.

LeMone, P., Burke, K., Dwyer, T., Levett-Jones, T., Moxham, L. and Reid-Searl, K., 2015. Medical-surgical nursing. Pearson Higher Education AU.

Marrie, T.J., Bartlett, J.G. and Thorner, A.R., 2013. Epidemiology, pathogenesis, and microbiology of community-acquired pneumonia in adults. UpToDate. URL: https://www. utdol. com/home/index. html.

Marti, A.T. and Esperatti, E.M., 2016. Community-acquired pneumonia. In Respiratory infections (pp. 110-128). CRC Press.

Petersson, J. and Glenny, R.W., 2014. Gas exchange and ventilation–perfusion relationships in the lung.

Ruuskanen, O., Lahti, E., Jennings, L.C. and Murdoch, D.R., 2011. Viral pneumonia. The Lancet, 377(9773), pp.1264-1275.

Saguil, A. and Fargo, M., 2012. Acute respiratory distress syndrome: diagnosis and management. American family physician, 85(4), pp.352-358..

Sue Eisenstadt, E., 2010. Dysphagia and aspiration pneumonia in older adults. Journal of the American Association of Nurse Practitioners, 22(1), pp.17-22.

Victor, L.Y., 2011. Guidelines for hospital-acquired pneumonia and health-care-associated pneumonia: a vulnerability, a pitfall, and a fatal flaw. The lancet infectious diseases, 11(3), pp.248-252.

Wagner, P.D. and West, J.B., 2012. Ventilation-Perfusion. Ventilation, Blood Flow, and Diffusion, p.219.

West, J.B., 2012. Respiratory physiology: the essentials. Lippincott Williams & Wilkins.

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