A patient diagnosed with pneumonia is experiencing worsening respiratory distress despite supplemental oxygen and antibiotic therapy. Which nursing intervention is most appropriate to prioritize in this situation?

C) Prepare for possible intubation and mechanical ventilation.

A) Increase the frequency of vital sign monitoring to every 15 minutes.

B) Administer a higher dose of Albuterol to alleviate bronchospasm.

C) Prepare for possible intubation and mechanical ventilation.

D) Elevate the head of the bed to a 45-degree angle to improve ventilation.

A patient diagnosed with pneumonia and experiencing worsening respiratory distress is being evaluated for potential ARDS. Which nursing intervention is most appropriate to prioritize at this time?

C) Prepare for transfer to the intensive care unit for possible mechanical ventilation.

A) Increase the flow rate of supplemental oxygen to maintain SpO2 above 95%.

B) Administer a bronchodilator to alleviate the use of accessory muscles.

C) Prepare for transfer to the intensive care unit for possible mechanical ventilation.

D) Encourage deep breathing exercises to improve lung expansion.

A patient in the ICU with a diagnosis of acute respiratory distress syndrome (ARDS) and respiratory acidosis is currently on non-invasive positive pressure ventilation (NIPPV). The arterial blood gas (ABG) shows a pH of 7.32, PaCO2 of 55 mmHg, and PaO2 of 58 mmHg on 60% oxygen. What is the priority nursing action to optimize the patient's respiratory status?

D) Assess the patient for proper mask fit and ensure effective seal with NIPPV.

A) Increase the oxygen concentration on the high-flow nasal cannula.

B) Initiate a bronchodilator therapy to reduce airway resistance.

C) Encourage deep breathing exercises to enhance oxygenation.

D) Assess the patient for proper mask fit and ensure effective seal with NIPPV.

A patient with acute respiratory distress syndrome (ARDS) is receiving non-invasive positive pressure ventilation (NIPPV) due to hypoxemia and respiratory acidosis. The arterial blood gas reveals a pH of 7.32, PaCO2 55 mmHg, and PaO2 58 mmHg on 60% oxygen. What is the most appropriate nursing intervention to improve gas exchange and prevent further respiratory deterioration?

B) Initiate prone positioning therapy.

A) Increase the flow rate of oxygen to 100%.

B) Initiate prone positioning therapy.

C) Administer a bronchodilator to reduce airway resistance.

D) Encourage deep breathing exercises every hour.

A patient with respiratory distress is being managed with non-invasive positive pressure ventilation (NIPPV). The patient's arterial blood gas analysis shows a pH of 7.35, PaCO2 of 50 mmHg, and PaO2 of 65 mmHg. Given these findings, what nursing intervention should the nurse prioritize at this time?

B) Continue monitoring the patient closely and reassess arterial blood gases regularly.

A) Initiate invasive mechanical ventilation immediately.

B) Continue monitoring the patient closely and reassess arterial blood gases regularly.

C) Discontinue NIPPV and switch to high-flow nasal cannula.

D) Reduce the frequency of monitoring as the patient's oxygen saturation has improved.

A patient on non-invasive positive pressure ventilation (NIPPV) for respiratory distress shows slight improvement in blood gases but remains clinically fragile with tachycardia and tachypnea. What is the most appropriate nursing action at this time?

C) Continue close monitoring and reassess the need for intubation if signs of respiratory failure persist.

A) Discontinue NIPPV and initiate invasive mechanical ventilation immediately.

B) Increase the FiO2 on the NIPPV to further improve oxygenation.

C) Continue close monitoring and reassess the need for intubation if signs of respiratory failure persist.

D) Initiate a rapid response team call to manage the patient's condition.

A patient with respiratory distress shows increased work of breathing, accessory muscle use, and hypoxemia despite non-invasive positive pressure ventilation (NIPPV). Arterial blood gas analysis reveals respiratory acidosis and hypoxemia. What is the most appropriate nursing action to prioritize in addressing this patient's condition?

B) Collaborate with the healthcare team to prepare for potential intubation.

A) Increase the oxygen flow rate to 10 L/min via face mask.

B) Collaborate with the healthcare team to prepare for potential intubation.

C) Administer a bronchodilator to improve ventilation.

D) Encourage the patient to perform deep breathing exercises.

Based on the patient's current condition and recent findings, what is the most appropriate initial nursing intervention to address the respiratory distress and potential infection?

B) Administer the newly prescribed targeted antibiotic therapy to address the drug-resistant Pseudomonas aeruginosa.

C) Initiate a continuous insulin infusion to better control hyperglycemia and reduce metabolic stress.

D) Prepare for the potential need for invasive mechanical ventilation by ensuring intubation equipment is readily available.

A patient with worsening respiratory status and suspected septic shock is being transitioned from non-invasive ventilation to invasive mechanical ventilation. What is the priority nursing intervention at this time?

C) Prepare the patient and equipment for endotracheal intubation.

A) Administer prescribed antibiotics to address the infection.

B) Initiate fluid resuscitation and monitor for signs of shock.

C) Prepare the patient and equipment for endotracheal intubation.

D) Educate the family about the patient's current condition and plan of care.

A patient with a drug-resistant Pseudomonas aeruginosa infection is experiencing worsening respiratory status despite being on non-invasive positive pressure ventilation. Her ABG results show a pH of 7.28, PaCO2 of 60 mmHg, and PaO2 of 55 mmHg, indicating respiratory acidosis and hypoxemia. The healthcare team considers escalating to invasive mechanical ventilation. Which of the following nursing interventions is the priority to address her current condition?

B) Prepare for endotracheal intubation and connect the patient to a mechanical ventilator

A) Administer a sedative to manage patient agitation before intubation

B) Prepare for endotracheal intubation and connect the patient to a mechanical ventilator

C) Initiate a fluid bolus to manage hypotension

D) Start vasopressor therapy to stabilize blood pressure

pneumonia - Nursing Case Study

Pathophysiology

• Primary mechanism: Infection of the alveoli by bacteria, viruses, or fungi leads to inflammation, causing alveolar sacs to fill with fluid or pus. This impairs gas exchange, resulting in symptoms like cough, fever, and difficulty breathing.

• Secondary mechanism: The immune response to the infection includes the release of cytokines, leading to further inflammation and recruitment of immune cells. This can cause additional lung tissue damage and exacerbate respiratory symptoms.

• Key complication: If not effectively managed, the inflammation and fluid accumulation can progress to acute respiratory distress syndrome (ARDS), significantly impairing oxygenation and potentially leading to respiratory failure.

Patient Profile

Demographics:

45-year-old female, school teacher

History:

• Key past medical history: Asthma, Type 2 Diabetes

• Current medications: Metformin, Albuterol inhaler, Lisinopril

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Shortness of breath and persistent cough

• Key symptoms: Fever, productive cough with yellow sputum, fatigue, pleuritic chest pain

• Vital signs: Temperature 38.5°C (101.3°F), Heart rate 110 bpm, Respiratory rate 28 breaths/min, Blood pressure 135/85 mmHg, Oxygen saturation 90% on room air

Section 1

The patient's initial assessment reveals bilateral crackles upon auscultation of the lungs, indicating the presence of fluid and consolidation consistent with pneumonia. Her respiratory distress is evident, with an increased effort to breathe, using accessory muscles and exhibiting nasal flaring. The productive cough has increased in frequency, producing thick yellow sputum, and her pleuritic chest pain intensifies with deep breaths and coughing. Despite the use of her Albuterol inhaler, her oxygen saturation remains low at 90% on room air, prompting the need for supplemental oxygen to maintain adequate saturation levels.

Laboratory tests indicate an elevated white blood cell count of 15,000/mm³, suggesting an active infectious process. A chest X-ray shows a right lower lobe infiltrate, confirming the diagnosis of pneumonia. Given her penicillin allergy, an alternative antibiotic regimen is initiated, including a macrolide such as azithromycin along with a respiratory fluoroquinolone, taking her history of asthma and diabetes into consideration. Blood cultures are also obtained to identify the causative organism and tailor antibiotic therapy if necessary.

Despite these interventions, the patient exhibits a new complication: her respiratory status continues to decline, with increasing dyspnea and her oxygen saturation dropping to 86% despite supplemental oxygen. Her respiratory rate climbs to 32 breaths per minute, and she develops mild cyanosis. Clinical reasoning suggests a progression towards acute respiratory distress syndrome (ARDS), necessitating an escalation in care. The healthcare team considers transferring her to a higher level of care, such as the intensive care unit, for closer monitoring and potential initiation of non-invasive ventilation or mechanical support to prevent further respiratory compromise.

Section 2

New Diagnostic Results:

As the patient is transferred to the intensive care unit, further diagnostic evaluations are conducted to better understand the progression of her condition. A repeat chest X-ray now shows bilateral infiltrates, indicating a possible progression to acute respiratory distress syndrome (ARDS). Additionally, an arterial blood gas analysis reveals a pH of 7.32, a PaCO2 of 55 mmHg, and a PaO2 of 58 mmHg on 60% oxygen via a high-flow nasal cannula, confirming respiratory acidosis and hypoxemia. These findings suggest that despite the current interventions, the patient's respiratory system is unable to adequately exchange gases, necessitating more aggressive management.

In light of the new diagnostic results, the healthcare team decides to initiate non-invasive positive pressure ventilation (NIPPV) to support the patient's breathing and improve oxygenation. Continuous monitoring is established to assess the effectiveness of this intervention and to ensure early recognition of any further deterioration. Additionally, a bronchoscopy is considered to obtain a more direct sample for culture and sensitivity testing, aiming to better tailor antibiotic therapy, as the patient's condition suggests potential complications such as a superimposed bacterial infection or atypical pathogen involvement.

The patient's metabolic panel also reveals an elevated blood glucose level of 320 mg/dL, likely exacerbated by stress and infection. This necessitates the initiation of an insulin sliding scale to manage hyperglycemia, which if uncontrolled, could further complicate her recovery by impairing immune function and delaying wound healing. The healthcare team remains vigilant, closely observing for any signs of systemic complications such as sepsis or multi-organ dysfunction, and is prepared to escalate care as needed to stabilize the patient and address any new challenges in her clinical course.

Section 3

The patient's response to the initiation of non-invasive positive pressure ventilation (NIPPV) is cautiously optimistic, as her oxygen saturation begins to improve, rising to 92% within the first hour of therapy. However, her clinical status remains fragile. Her heart rate is recorded at 112 beats per minute, blood pressure at 138/85 mmHg, and respiratory rate at 28 breaths per minute, indicating persistent tachycardia and tachypnea despite improved oxygenation. The nursing team notes that the patient appears more alert but still exhibits signs of respiratory distress, such as the use of accessory muscles and intermittent coughing.

The repeat arterial blood gas analysis after two hours on NIPPV shows a slight improvement in gas exchange, with a pH of 7.35, PaCO2 of 50 mmHg, and PaO2 of 65 mmHg. While these values indicate a positive trend, they also suggest that the patient is not yet fully compensating for her respiratory acidosis, warranting continued close monitoring. The healthcare team discusses the next steps, considering the potential need for escalation to invasive mechanical ventilation if the patient's respiratory effort becomes inadequate or if her condition deteriorates further.

In parallel, the results of the bronchoscopy are pending, leaving the team with the task of empirically broadening antibiotic coverage to address potential atypical pathogens or resistant organisms. The patient's glucose levels are gradually stabilizing under the insulin sliding scale, with recent readings showing a decrease to 270 mg/dL, yet the team remains vigilant for any signs of systemic complications. The focus now shifts to maintaining the delicate balance of supporting the patient's respiratory function while preventing further metabolic derangements, anticipating the need for swift intervention should her clinical status take a turn for the worse.

Section 4

As the healthcare team continues to monitor the patient closely, a new complication emerges. During the next nursing assessment, the patient is noted to have increased work of breathing, with a respiratory rate climbing to 32 breaths per minute and oxygen saturation dropping slightly to 90% despite the continued use of NIPPV. She begins to show signs of increasing fatigue, and her use of accessory muscles becomes more pronounced. Her heart rate remains elevated at 115 beats per minute, and her blood pressure measures 140/88 mmHg. The patient expresses feelings of anxiety and reports worsening cough with more productive sputum, which has taken on a greenish tinge, suggesting a possible superimposed infection or ineffective antibiotic coverage.

In response to these changes, a repeat arterial blood gas analysis is performed, revealing a pH of 7.32, PaCO2 of 54 mmHg, and PaO2 of 60 mmHg. These results indicate worsening respiratory acidosis and hypoxemia, raising concerns about her ability to maintain adequate gas exchange. The healthcare team discusses the potential need for escalating respiratory support to invasive mechanical ventilation to prevent further deterioration. Concurrently, the pending bronchoscopy results arrive, identifying the presence of drug-resistant Pseudomonas aeruginosa, prompting an immediate adjustment in her antibiotic regimen to include a more targeted therapy.

The team also reevaluates her glucose management, noting that while her levels have decreased to 240 mg/dL, the stress of her respiratory distress may be contributing to persistent hyperglycemia. They consider the addition of a continuous insulin infusion to achieve better control, recognizing the importance of optimizing metabolic function to support her overall recovery. The focus remains on stabilizing her condition while preparing for potential interventions, ensuring that all measures are in place to address any further complications swiftly.

Section 5

Over the next several hours, the healthcare team implements the adjusted antibiotic regimen targeting the drug-resistant Pseudomonas aeruginosa, and the patient is started on a continuous insulin infusion to address her persistent hyperglycemia. Despite these interventions, her respiratory status continues to worsen. The patient's respiratory rate remains elevated, and her oxygen saturation further declines to 86%, despite maximizing the settings on the non-invasive positive pressure ventilation (NIPPV). She exhibits increased lethargy and confusion, indicating a decline in her neurological status, likely secondary to worsening hypoxemia and hypercapnia.

A repeat arterial blood gas analysis shows further deterioration with a pH of 7.28, PaCO2 of 60 mmHg, and PaO2 of 55 mmHg, confirming that her respiratory acidosis and hypoxemia are not improving with current supportive measures. The healthcare team decides to escalate to invasive mechanical ventilation to provide more effective respiratory support and prevent further decline. Meanwhile, her heart rate climbs to 130 beats per minute, and her blood pressure begins to drop to 110/70 mmHg, suggesting the onset of septic shock, likely due to the superimposed infection.

In response to these developments, the team initiates fluid resuscitation and considers vasopressor support to stabilize her hemodynamic status. Continuous monitoring is prioritized to assess the effectiveness of these interventions and to detect any further complications promptly. The focus now shifts to achieving hemodynamic stability and improving gas exchange to support her recovery. The team prepares for the possibility of additional interventions, including advanced hemodynamic monitoring and adjunctive therapies, to optimize her condition and prevent further deterioration.