pnuemonia - Nursing Case Study

Pathophysiology

• Primary mechanism: Inhalation or aspiration of pathogens triggers inflammation in the lungs. This results in alveoli filling with fluid and pus, reducing oxygen exchange capacity and causing symptoms like coughing, chest pain, and difficulty breathing.

• Secondary mechanism: The immune response to the infection can further damage lung tissue. Neutrophils and macrophages release enzymes and reactive oxygen species, which can damage both bacterial cells and host lung tissue, exacerbating symptoms.

• Key complication: Severe pneumonia can lead to sepsis, a systemic inflammatory response. It can cause multi-organ failure and is potentially life-threatening if not promptly treated.

Patient Profile

Demographics:

68-year-old male, retired construction worker

History:

• Key past medical history: Diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and Type 2 Diabetes

• Current medications: Metformin, Salbutamol Inhaler

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent cough with greenish phlegm, shortness of breath, and high fever for the past week

• Key symptoms: Chest pain, fatigue, loss of appetite, sweating, and confusion

• Vital signs: Temperature of 102°F, blood pressure 145/90 mmHg, pulse rate 110 bpm, respiratory rate 28 breaths per minute, oxygen saturation 88% on room air

Section 1

Change in Patient Status:

The patient's condition has deteriorated over the past 24 hours. His oxygen saturation has dropped to 82% on room air, and he is now requiring 2 liters of supplemental oxygen via nasal cannula to maintain a saturation level above 90%. His respiratory rate has increased to 30 breaths per minute and his temperature has risen to 103°F. He also appears more confused than before, unable to answer basic questions about his name and date of birth.

The patient's blood pressure has also spiked to 160/95 mmHg, and his pulse rate has increased to 120 bpm. Additionally, the patient has begun to exhibit signs of cyanosis, with his lips and fingertips turning blue. He continues to cough up greenish phlegm and his chest pain has intensified. The patient's worsening hypoxia, confusion, and increased respiratory rate suggest a possible development of respiratory failure, which is a life-threatening complication requiring immediate medical intervention. This could be due to the progression of his pneumonia, exacerbated by his underlying COPD.

The patient's significant change in status requires a re-evaluation of his management plan and possibly more aggressive intervention. The healthcare team needs to consider the potential risk factors such as his age, COPD, and diabetes which can complicate his pneumonia and potentially increase his risk of developing complications like respiratory failure and sepsis. Prompt diagnostic tests should be performed to identify the severity and cause of the pneumonia, and appropriate treatment initiated accordingly.

Section 2

New Diagnostic Results:

Upon re-evaluation, the healthcare team decided to perform a chest X-ray and blood tests to further investigate the patient's deteriorating condition. The X-ray report showed a progression of consolidation in the right lower lobe of his lung, indicating an increased infection spread. His blood tests revealed an elevated white blood cell count of 18,000 per microliter (normal range: 4,500-11,000), a sign of bacterial infection. The blood gas analysis revealed a low partial pressure of oxygen (PaO2) at 60 mmHg (normal range: 75-100 mmHg) and a high partial pressure of carbon dioxide (PaCO2) at 50 mmHg (normal range: 35-45 mmHg), suggesting acute respiratory acidosis secondary to hypoventilation.

The patient's arterial blood gas (ABG) results, along with his increased respiratory rate and confusion, are consistent with hypercapnic respiratory failure, a condition wherein the body can't eliminate enough carbon dioxide. The blood culture results are still pending, which could provide further insights into the specific bacteria causing the infection. These diagnostic results necessitate an immediate modification in the treatment plan to reverse the escalating threat to the patient's respiratory system. The team also needs to monitor the patient for signs of sepsis, given his elevated white blood cell count and high fever.

Section 3

Change in Patient Status:

Over the next few hours, the patient's condition worsened. His respiratory rate increased to 32 breaths per minute, and his oxygen saturation dropped to 86% on room air. His temperature spiked to 102.5°F, and his blood pressure fell to 90/60 mmHg. The patient was noted to be increasingly lethargic and disoriented, unable to answer simple questions correctly. His skin appeared pale and clammy, and his peripheral pulses were weak.

These changes suggest that the patient's respiratory status is deteriorating, and he may be developing septic shock, a severe and potentially life-threatening condition that can occur in response to an infection. The decreasing blood pressure and increasing heart rate indicate that his body is struggling to maintain adequate perfusion to vital organs. His altered mental status could be a result of decreased oxygen delivery to his brain. The healthcare team needs to act swiftly to stabilize the patient and prevent further deterioration. This might include starting broad-spectrum antibiotics, fluid resuscitation, and potentially initiating mechanical ventilation.

Section 4

New Diagnostic Results:

A repeat chest x-ray was performed, which showed significantly increased consolidation in both of the lung fields. The patient's blood cultures came back positive for Streptococcus pneumoniae, confirming the diagnosis of pneumonia. His arterial blood gas (ABG) showed severe hypoxemia with a PaO2 of 52 mmHg and a PaCO2 of 35 mmHg, suggesting that the patient was not adequately ventilating or oxygenating. His WBC count was elevated at 18,000 per microliter, indicative of an ongoing infection.

These results are alarming and indicate that not only is the patient's pneumonia progressing, but he also has a severe infection that is not being adequately controlled. With the confirmation of Streptococcus pneumoniae in the blood cultures, the medical team can now tailor the antibiotics to this specific pathogen. However, the patient's worsening ABG results and increasing respiratory rate suggest that he is in acute respiratory failure, which may necessitate the initiation of mechanical ventilation. The team must quickly decide on the best course of action to manage these rapidly developing complications.

Section 5

Change in Patient Status:

The patient's condition continues to deteriorate, with his respiratory rate now at 32 breaths per minute and oxygen saturation dropping to 85% on room air. He appears lethargic, with diminished breath sounds bilaterally and cyanosis of the lips. His heart rate has increased to 110 beats per minute, and his blood pressure is 110/70 mmHg, indicative of potential compensatory tachycardia.

The patient's worsening condition is indicative of progressive respiratory failure, which could lead to a life-threatening condition such as septic shock or acute respiratory distress syndrome (ARDS). He is barely maintaining his oxygen saturation despite supplemental oxygen, and his rapid, shallow breathing indicates respiratory distress. The cyanosis of his lips is a late sign of hypoxia. The team must quickly reassess the patient's status, consider the possibility of intubation and mechanical ventilation, and monitor him closely for signs of further deterioration.