A patient with a history of asthma is admitted with a diagnosis of right lower lobe pneumonia. The nurse observes the patient using accessory muscles for breathing and notes mild cyanosis around the lips. Which of the following actions should the nurse prioritize to address the patient's respiratory distress?

B) Administer a prescribed bronchodilator and reassess respiratory status.

A) Increase the supplemental oxygen to 6 L/min via nasal cannula.

B) Administer a prescribed bronchodilator and reassess respiratory status.

C) Perform chest physiotherapy to mobilize secretions.

D) Encourage deep breathing and coughing exercises.

A patient with a history of asthma presents with pneumonia characterized by labored breathing, use of accessory muscles, and cyanosis around the lips. Which nursing intervention should be prioritized to address the primary concern of hypoxemia in this patient?

B) Increase supplemental oxygen to achieve adequate oxygen saturation.

A) Administer bronchodilator treatment to prevent bronchospasm.

B) Increase supplemental oxygen to achieve adequate oxygen saturation.

C) Position the patient in high Fowler's position to facilitate lung expansion.

D) Encourage deep breathing and coughing exercises to mobilize secretions.

A patient with pneumonia is experiencing persistent hypoxemia and respiratory acidosis despite supplemental oxygen therapy. Given the presence of a small pleural effusion and increased respiratory distress, what is the most appropriate nursing intervention to prioritize at this time?

C) Transition the patient to high-flow oxygen therapy

A) Increase the flow rate of the nasal cannula

B) Prepare the patient for thoracentesis

C) Transition the patient to high-flow oxygen therapy

D) Administer bronchodilators to relieve respiratory distress

A patient with a small right-sided pleural effusion, respiratory acidosis, and persistent hypoxemia is being transitioned from nasal cannula to high-flow oxygen therapy. Which additional nursing intervention is most appropriate to support this patient's respiratory status?

A) Encourage deep breathing and coughing exercises.

B) Place the patient in a supine position to facilitate lung expansion.

C) Administer a bronchodilator to alleviate airway constriction.

D) Restrict fluid intake to prevent further pleural effusion.

A nurse is caring for a patient who underwent a thoracentesis to relieve a pleural effusion and is now exhibiting respiratory acidosis with minimal improvement. Which intervention should the nurse prioritize to address the patient's current respiratory status?

B) Administer nebulized bronchodilators as prescribed

A) Increase the flow rate of oxygen delivery

B) Administer nebulized bronchodilators as prescribed

C) Encourage the patient to perform incentive spirometry

D) Position the patient in a high Fowler's position

A nurse is caring for a patient who recently underwent a thoracentesis due to a pleural effusion and continues to exhibit signs of respiratory distress. Which of the following nursing interventions is most appropriate to prioritize in this situation?

D) Administer nebulized bronchodilators as prescribed to reduce bronchospasm.

A) Encourage the patient to perform incentive spirometry every hour.

B) Increase the flow rate of oxygen therapy to improve oxygen saturation.

C) Monitor for signs of infection and send repeat fluid samples for analysis.

D) Administer nebulized bronchodilators as prescribed to reduce bronchospasm.

A patient with a history of chronic respiratory disease is experiencing fluctuating oxygen saturation, labored breathing, and a low-grade fever. Recent interventions include thoracentesis and broad-spectrum antibiotic therapy. Which complication should the nurse prioritize monitoring for, given the current clinical findings?

A) Acute respiratory distress syndrome (ARDS)

A patient with a recent thoracentesis and ongoing high-flow oxygen therapy is experiencing fluctuating oxygen saturation levels and labored breathing. She has developed a fever and elevated white blood cell count, indicating a potential infection. Which nursing intervention is most appropriate to prioritize for this patient?

C) Monitor vital signs closely and prepare to assist with possible intubation.

A) Administer antipyretics to address the fever and provide comfort.

B) Increase the flow rate of oxygen to improve oxygenation status.

C) Monitor vital signs closely and prepare to assist with possible intubation.

D) Implement strict infection control measures to prevent cross-contamination.

A patient with confirmed Streptococcus pneumoniae infection is showing signs of potential acute respiratory distress syndrome (ARDS) with worsening oxygenation and increased respiratory rate. Which intervention should the nurse prioritize to address the patient's current respiratory status?

B) Prepare the patient for potential intubation and mechanical ventilation.

A) Increase the flow rate of supplemental oxygen.

B) Prepare the patient for potential intubation and mechanical ventilation.

C) Encourage deep breathing and coughing exercises.

D) Administer an anxiolytic to manage the patient's anxiety.

A patient with confirmed Streptococcus pneumoniae infection is receiving high-dose intravenous penicillin and broad-spectrum antibiotics. Despite treatment, her oxygen saturation remains unstable, and she exhibits signs of respiratory distress. What should be the nurse's priority intervention to address the patient's current respiratory status?

B) Prepare the patient for potential mechanical ventilation and notify the healthcare provider.

A) Increase the flow rate of supplemental oxygen to maintain adequate saturation.

B) Prepare the patient for potential mechanical ventilation and notify the healthcare provider.

C) Encourage the patient to use incentive spirometry to improve lung expansion.

D) Position the patient in a semi-Fowler's position to facilitate breathing.

pneumonia - Nursing Case Study

Pathophysiology

• Primary mechanism: Inflammatory response - Pneumonia is initiated by the invasion of pathogens (bacteria, viruses, fungi) into the alveoli, triggering an inflammatory response that results in the accumulation of fluid and immune cells in the alveolar sacs, impairing gas exchange.

• Secondary mechanism: Alveolar-capillary membrane damage - The inflammation can damage the alveolar-capillary membrane, leading to increased permeability and further fluid leakage into the alveoli, exacerbating hypoxia.

• Key complication: Impaired oxygenation - The accumulation of fluid and debris in the alveoli decreases lung compliance and ventilation-perfusion mismatch, resulting in reduced oxygenation of blood, which can lead to respiratory distress and organ dysfunction if untreated.

Patient Profile

Demographics:

45-year-old female, school teacher

History:

• Key past medical history: Asthma diagnosed 10 years ago, hypertension

• Current medications: Albuterol inhaler, Lisinopril 10 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent cough and shortness of breath

• Key symptoms: Fever, productive cough with green sputum, fatigue, chest pain during deep breaths

• Vital signs: Temperature 101.3°F, heart rate 110 bpm, respiratory rate 24 breaths per minute, blood pressure 140/85 mmHg, oxygen saturation 90% on room air

Section 1

As the medical team proceeded with the initial assessment, they observed that the patient's respiratory effort was labored, with the use of accessory muscles evident. Auscultation of the lungs revealed coarse crackles and diminished breath sounds, particularly over the right lower lobe, suggesting consolidation. The patient exhibited mild cyanosis around the lips, indicating significant hypoxemia. The clinical team promptly initiated supplemental oxygen therapy via nasal cannula at 4 L/min to improve her oxygenation status.

Laboratory and imaging tests were ordered to confirm the diagnosis and assess the severity of the pneumonia. A complete blood count (CBC) revealed leukocytosis with a white blood cell count of 15,000/mm³, suggesting an ongoing bacterial infection. C-reactive protein (CRP) was elevated, further supporting the inflammatory response. A chest X-ray showed opacity in the right lower lobe consistent with lobar pneumonia. Given her history of asthma, the team was concerned about the risk of bronchospasm complicating her respiratory status, and a bronchodilator was administered as a precaution.

The team discussed the potential for complications such as pleural effusion or lung abscess if the pneumonia progressed. They emphasized monitoring for signs of increasing respiratory distress, such as worsening hypoxia or tachypnea, and planned for regular reassessment of her respiratory function and vital signs. The patient's asthma history also necessitated vigilant management to prevent exacerbation, and adjustments to her asthma management plan were considered in light of the current infection. With these considerations, the team prepared to address any emerging complications promptly while continuing to manage her current symptoms.

Section 2

As the medical team continued to monitor the patient’s progress, they noted a change in her status over the next 24 hours. Despite the supplemental oxygen therapy, her oxygen saturation levels remained suboptimal, fluctuating between 88% and 90%, indicating persistent hypoxemia. Her respiratory rate increased to 28 breaths per minute, and the use of accessory muscles became more pronounced, suggesting escalating respiratory distress. The patient also reported increased pleuritic chest pain, particularly on deep inspiration, which was concerning for a potential pleural complication.

In light of these developments, a repeat chest X-ray was ordered, which revealed the presence of a small right-sided pleural effusion. This finding prompted further evaluation through ultrasound to assess the nature and extent of the effusion. Concurrently, her blood gas analysis indicated a respiratory acidosis with a pH of 7.32 and a PaCO2 of 48 mmHg, confirming impaired ventilation. These results highlighted the need for more aggressive intervention to manage her respiratory status and prevent further decline.

The clinical team decided to escalate the level of respiratory support, transitioning from nasal cannula to a high-flow oxygen system to better address her hypoxemia. Additionally, they initiated diuretic therapy to manage the pleural effusion and consulted with the pulmonology team to consider potential thoracentesis if the effusion persisted or worsened. The patient’s asthma management was also re-evaluated, with a focus on optimizing her inhaled corticosteroid therapy to prevent bronchospasm. These interventions aimed to stabilize her condition and address the complications arising from her pneumonia, setting the stage for ongoing management and observation.

Section 3

In the subsequent 12 hours following the escalation of respiratory support and initiation of diuretic therapy, the patient's clinical status showed mixed responses. Her oxygen saturation improved slightly to a range of 90% to 92% with high-flow oxygen, indicating a modest response to the increased oxygen delivery. However, her respiratory distress remained significant, with a respiratory rate persisting at 26 breaths per minute and continued use of accessory muscles, suggesting that her ventilation issues were not fully resolved. The patient's pleuritic chest pain also persisted, raising concerns about the progression of her pleural effusion.

A follow-up ultrasound revealed that the right-sided pleural effusion had slightly increased in size. The pulmonology team, after careful consideration, decided to proceed with a thoracentesis to relieve the pressure from the accumulating fluid and provide symptomatic relief. The procedure yielded 300 mL of serous fluid, which was sent for analysis to rule out infection or other underlying causes. Post-thoracentesis, the patient reported a slight decrease in chest pain, and her respiratory rate showed a marginal improvement to 24 breaths per minute, although her oxygen requirements remained high.

Despite these interventions, the patient's arterial blood gas analysis continued to reflect respiratory acidosis with minimal improvement, now showing a pH of 7.34 and PaCO2 of 46 mmHg. The clinical team recognized the need to further optimize her asthma management and considered the use of nebulized bronchodilators to mitigate any bronchospasm that might be contributing to her impaired ventilation. This approach aimed to address both the immediate respiratory issues and the underlying chronic conditions, setting the stage for careful monitoring of her response and adjustment of her treatment regimen.

Section 4

In the next 12 hours, the clinical team observed a change in the patient's status that prompted additional interventions. Despite the thoracentesis and ongoing high-flow oxygen therapy, the patient's oxygen saturation began to fluctuate, intermittently dropping to 88% during periods of minimal exertion, such as repositioning in bed. Her respiratory rate remained elevated at 25 breaths per minute, and she continued to exhibit labored breathing with pronounced use of accessory muscles. Notably, auscultation of her lungs now revealed diminished breath sounds in the right lower lobe with scattered crackles, suggesting possible alveolar involvement or further consolidation.

Concurrent with these respiratory challenges, the patient developed a low-grade fever of 38.2°C (100.8°F), and her white blood cell count rose to 14,500/mm³, indicating a potential infectious process. Blood cultures and a repeat sputum culture were obtained to identify any bacterial pathogens contributing to her deteriorating condition. Given the complexity of her respiratory status and the new onset of fever, the clinical team expanded her antibiotic coverage to include broader-spectrum agents, targeting both typical and atypical respiratory pathogens, while awaiting culture results.

As the patient's condition remained tenuous, the healthcare team considered the potential for new complications such as bacterial superinfection or an evolving pneumonia pattern. This necessitated close monitoring of her vital signs and laboratory values, with a heightened focus on early detection and management of sepsis. The clinical reasoning process was further challenged by the need to balance aggressive treatment with the patient's underlying chronic conditions, requiring a multidisciplinary approach to optimize her respiratory function while addressing emerging complications.

Section 5

As the clinical team continued to monitor the patient closely, new diagnostic results revealed further insight into her condition. The blood cultures returned positive for Streptococcus pneumoniae, confirming the presence of a bacterial superinfection contributing to her deteriorating respiratory status. The repeat sputum culture also identified the same pathogen, underscoring the need for targeted antimicrobial therapy. In response to these findings, the clinical team adjusted the antibiotic regimen to include high-dose intravenous penicillin, known to be effective against Streptococcus pneumoniae, in addition to the broad-spectrum antibiotics already in place.

Despite the tailored antibiotic therapy, the patient's condition showed signs of further complication. Her oxygen saturation remained unstable, occasionally dipping to as low as 85% with minimal exertion, necessitating frequent adjustments to her high-flow oxygen settings. Her respiratory rate increased to 28 breaths per minute, and she demonstrated increasing fatigue and anxiety, likely due to the persistent hypoxemia. A repeat chest X-ray revealed further consolidation in the right lower lobe, suggesting progression of the pneumonia despite initial interventions.

These developments prompted the healthcare team to reassess their management strategy. The potential for acute respiratory distress syndrome (ARDS) was considered, given the patient's worsening gas exchange and the pattern of lung involvement. The interdisciplinary team, including pulmonologists and critical care specialists, engaged in discussions about the possibility of escalating respiratory support, potentially considering non-invasive ventilation or even mechanical ventilation if the patient's condition failed to improve. The team emphasized the importance of balancing aggressive interventions with the patient's overall health status and quality of life, ensuring that each step was guided by thoughtful clinical reasoning and patient-centered care.