A nurse is caring for a patient with worsening respiratory distress, diagnosed with pneumonia and a small pleural effusion. Despite receiving 4 L/min of supplemental oxygen via nasal cannula, the patient's oxygen saturation remains suboptimal at 89%. The patient has a history of asthma and is showing signs of fatigue and confusion. What is the most appropriate nursing intervention to improve the patient's respiratory status?

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

C) Prepare for intubation and mechanical ventilation.

D) Administer a bronchodilator and reassess respiratory status.

A patient with a history of asthma is admitted with worsening pneumonia and is now showing signs of respiratory distress, confusion, and pleuritic chest pain. The healthcare team is considering non-invasive positive pressure ventilation (NIPPV) due to her declining respiratory status. What is the priority nursing intervention to perform at this time?

C) Monitor the patient's mental status and respiratory effort closely.

A) Increase the oxygen flow rate on the nasal cannula to 6 L/min.

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

C) Monitor the patient's mental status and respiratory effort closely.

D) Administer a bronchodilator and reassess lung sounds.

A patient with asthma and pneumonia is exhibiting signs of acute respiratory failure, including a respiratory rate of 32 breaths per minute, oxygen saturation of 86% on 6 L/min nasal cannula, and confusion. The healthcare team initiates non-invasive positive pressure ventilation (NIPPV). What is the primary nursing intervention to monitor the effectiveness of NIPPV in this patient?

A) Monitor for changes in respiratory rate and oxygen saturation

B) Check blood glucose levels regularly

C) Assess for signs of deep vein thrombosis

D) Monitor intake and output for fluid balance

A patient with underlying asthma and pneumonia is showing signs of acute respiratory failure. Her current interventions include non-invasive positive pressure ventilation (NIPPV) and adjusted antibiotic therapy. Which of the following interventions should the nurse prioritize to address her elevated lactate level and suspected sepsis, while considering her respiratory status?

B) Initiate intravenous fluid resuscitation with careful monitoring for signs of fluid overload

A) Increase the flow rate of supplemental oxygen to 10 L/min via nasal cannula

B) Initiate intravenous fluid resuscitation with careful monitoring for signs of fluid overload

C) Administer a bronchodilator to manage underlying asthma exacerbation

D) Schedule a repeat arterial blood gas analysis to track respiratory status

A patient with a complicated parapneumonic effusion and confirmed Streptococcus pneumoniae infection is showing signs of increased work of breathing and altered mental status despite NIPPV support. Her blood pressure has dropped to 90/60 mmHg, indicating potential septic shock. What is the nurse's priority action to address this patient's current condition?

C) Administer a bolus of intravenous fluids to stabilize hemodynamics.

A) Increase the oxygen flow rate to improve oxygenation.

B) Initiate vasopressor therapy as soon as possible.

C) Administer a bolus of intravenous fluids to stabilize hemodynamics.

D) Reassess the patient's neurological status for signs of cerebral hypoxia.

A patient with a confirmed diagnosis of complicated parapneumonic effusion and Streptococcus pneumoniae is experiencing a drop in blood pressure to 90/60 mmHg and signs of septic shock despite non-invasive positive pressure ventilation. What would be the most appropriate nursing intervention to prioritize at this time?

B) Initiate a fluid bolus to address the hypotension while monitoring for fluid overload.

A) Increase the rate of the current broad-spectrum antibiotic infusion.

B) Initiate a fluid bolus to address the hypotension while monitoring for fluid overload.

C) Administer a sedative to reduce the patient's respiratory rate and work of breathing.

D) Prepare for the insertion of a chest tube to drain the pleural effusion immediately.

A patient in septic shock is experiencing worsening mental status, cool and clammy skin, and decreased urine output despite ongoing interventions. Which nursing action is the highest priority to address this patient's condition?

B) Administer a bolus of intravenous crystalloids to improve perfusion.

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

B) Administer a bolus of intravenous crystalloids to improve perfusion.

C) Initiate continuous renal replacement therapy to manage acute kidney injury.

D) Collaborate with the respiratory therapist to optimize oxygen delivery.

A patient in septic shock is showing signs of potential multi-organ dysfunction, including decreased urine output and rising creatinine levels. Despite fluid resuscitation, her blood pressure remains unstable, and norepinephrine is initiated. Which of the following nursing interventions is the most critical to perform next to assess the effectiveness of the current treatment strategy?

D) Check the patient's urine output hourly to monitor renal function.

A) Measure the patient's central venous pressure (CVP) to assess fluid status.

B) Monitor the patient's Glasgow Coma Scale (GCS) score for changes in neurological status.

C) Evaluate the patient's capillary refill time to assess peripheral perfusion.

D) Check the patient's urine output hourly to monitor renal function.

A patient with sepsis has developed early-stage disseminated intravascular coagulation (DIC) and is receiving fresh frozen plasma and platelet transfusions. As the nurse assigned to this patient, which of the following assessments is the most critical to perform to evaluate the effectiveness of the treatment for DIC?

A) Monitoring for signs of bleeding such as petechiae and hematuria

B) Checking for improvement in mental status and orientation

C) Assessing for decreased heart rate and stabilization of vital signs

D) Observing for any allergic reactions to blood products

A patient with septic shock is diagnosed with early-stage disseminated intravascular coagulation (DIC), evidenced by a low platelet count, prolonged PT and aPTT, and decreased fibrinogen levels. The nursing team is administering fresh frozen plasma and platelet transfusions. During this process, the nurse notes a new onset of confusion in the patient. Which of the following should be the nurse's priority action?

A) Assess the patient's oxygen saturation and respiratory status

B) Reassess the patient's vital signs, paying close attention to blood pressure

C) Check the patient's blood glucose levels for hypoglycemia

D) Review the patient's medication administration record for potential side effects

community-acquired pneumonia - Nursing Case Study

Pathophysiology

• Primary mechanism: Inhalation of pathogens like Streptococcus pneumoniae leads to alveolar inflammation. The immune response, including neutrophil infiltration, results in the accumulation of exudate in alveoli, impairing gas exchange and causing respiratory symptoms.

• Secondary mechanism: The systemic inflammatory response can result in cytokine release, which may cause fever and malaise. This systemic response helps mobilize immune cells but can also contribute to the severity of symptoms and complications.

• Key complication: If unchecked, the infection can lead to bacteremia or sepsis, where bacteria enter the bloodstream, potentially causing widespread organ dysfunction and increased mortality risk. Early recognition and treatment are crucial to prevent these severe outcomes.

Patient Profile

Demographics:

45-year-old female, school teacher

History:

• Key past medical history: Asthma diagnosed 10 years ago

• Current medications: Albuterol inhaler as needed, Fluticasone propionate 100 mcg twice daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent cough and difficulty breathing

• Key symptoms: Fever, productive cough with green sputum, shortness of breath, pleuritic chest pain, fatigue

• Vital signs: Temperature 102.1°F (38.9°C), Heart rate 110 bpm, Blood pressure 100/60 mmHg, Respiratory rate 24 breaths per minute, Oxygen saturation 88% on room air

Section 1

As the healthcare team continues to monitor the patient, they note a change in her status. Her respiratory distress worsens, with an increase in respiratory rate to 28 breaths per minute and a further decline in oxygen saturation to 84% on room air. Despite supplemental oxygen administered via nasal cannula at 4 L/min, her oxygen levels only marginally improve to 89%. The patient also reports increased pleuritic chest pain and appears more fatigued, with periods of confusion noted by the nursing staff. These symptoms, combined with her elevated heart rate of 118 bpm, suggest a possible progression to a more severe state of pneumonia or a developing complication.

A chest X-ray is ordered and reveals consolidation in the right lower lobe, consistent with pneumonia, but also indicates a small pleural effusion. Laboratory tests return with a white blood cell count of 14,000/mm³, elevated C-reactive protein (CRP), and procalcitonin levels suggestive of a significant bacterial infection. Blood cultures are pending to assess for bacteremia. Given the patient's history of asthma and the current state of her pulmonary function, there is a concern for impending respiratory failure. The healthcare team initiates broad-spectrum antibiotics, avoiding penicillin due to her allergy, and considers the need for more aggressive respiratory support, such as non-invasive positive pressure ventilation (NIPPV), if her condition does not stabilize.

As the case unfolds, the clinical team must carefully monitor for signs of sepsis, given her systemic inflammatory response and altered mental status. Fluid management and further evaluation of her pleural effusion may be necessary, considering the potential need for thoracentesis if the effusion compromises her breathing further. The focus remains on stabilizing her respiratory status while addressing the underlying infection to prevent further deterioration.

Section 2

As the healthcare team continues their vigilant monitoring of the patient, they observe a change in her status that prompts immediate attention. Her respiratory distress has escalated, evident by an increase in respiratory rate to 32 breaths per minute, and her oxygen saturation remains critically low at 86% despite increasing supplemental oxygen to 6 L/min via nasal cannula. Her heart rate has risen to 130 bpm, and she exhibits increased confusion and lethargy, indicating a worsening of her mental status. These changes suggest that the patient may be progressing towards acute respiratory failure, a concern given her underlying asthma and current pneumonia diagnosis.

In response to these alarming developments, the care team decides to initiate non-invasive positive pressure ventilation (NIPPV) to enhance her oxygenation and reduce the work of breathing. Alongside this intervention, they review her medications and adjust her antibiotic regimen to ensure optimal coverage for potential atypical pathogens while avoiding allergens. Serial arterial blood gases are performed, revealing a PaO2 of 55 mmHg and a PaCO2 of 50 mmHg, confirming hypoxemic respiratory failure with partial hypercapnia. Her lactate level is elevated at 3.2 mmol/L, raising suspicion for sepsis and prompting the team to expedite fluid resuscitation with careful monitoring to prevent fluid overload, particularly given the existing pleural effusion.

The patient's pleural effusion is reassessed, and given its persistence and the patient's deteriorating condition, the team plans a bedside ultrasound-guided thoracentesis to both relieve symptoms and obtain fluid for analysis to help guide further treatment. The procedure is scheduled urgently, and the nursing staff remains alert to any further changes in her condition, ready to escalate care as necessary. As the team works to stabilize the patient, they continue to await blood culture results, which will be crucial in tailoring her antibiotic therapy and ensuring comprehensive management of her infection.

Section 3

Shortly after initiating non-invasive positive pressure ventilation (NIPPV), the healthcare team observes a modest improvement in the patient's oxygenation, as her oxygen saturation increases to 90%. However, her respiratory rate remains elevated at 30 breaths per minute, and she continues to exhibit signs of increased work of breathing. The patient still appears lethargic, and her confusion persists, raising concerns about cerebral hypoxia. The nursing team conducts a thorough assessment, noting accessory muscle use and diminished breath sounds bilaterally, indicating that the underlying pulmonary pathology is still significantly affecting her respiratory function.

New diagnostic results come in, providing further insight into the patient's condition. The fluid analysis from the thoracentesis reveals an exudative effusion with a high protein content and a predominance of neutrophils, suggestive of a complicated parapneumonic effusion. Meanwhile, blood cultures return positive for Streptococcus pneumoniae, confirming the bacterial cause of her pneumonia. With this information, the care team tailors her antibiotic regimen by adding a more targeted beta-lactam antibiotic to ensure effective eradication of the pathogen while continuing with broad-spectrum coverage until further sensitivity results are available.

Despite the initial response to NIPPV, the patient's condition takes a concerning turn as her blood pressure drops to 90/60 mmHg, prompting suspicion of septic shock. The team ramps up fluid resuscitation efforts, carefully balancing the risk of exacerbating her pleural effusion. In response, the critical care team considers transitioning to more aggressive measures, such as vasopressors, to support her hemodynamic status. As they navigate these challenges, the multidisciplinary team remains vigilant in reassessing the patient's response and adjusting the treatment plan to address the evolving complexity of her condition.

Section 4

As the patient's condition continues to be monitored, a sudden change in her status becomes apparent. Despite the ongoing interventions, her mental status worsens, and she now exhibits signs of acute confusion and restlessness, indicating potential progression to delirium. Her Glasgow Coma Scale (GCS) score has decreased to 12, with particular deficits in verbal response and orientation. Nursing assessments reveal her skin is cool and clammy, and her capillary refill time has extended beyond 3 seconds, further confirming peripheral hypoperfusion. These signs, coupled with a persistent elevated lactate level of 4.5 mmol/L, suggest that her septic shock is not adequately controlled, raising concerns for potential progression to multi-organ dysfunction.

In response to these alarming developments, the critical care team intensifies their intervention strategy. Vasopressor therapy is initiated with norepinephrine to stabilize her blood pressure, which has not improved significantly despite aggressive fluid resuscitation. Her urine output has decreased to less than 0.5 mL/kg/hr, prompting the team to closely monitor renal function, as acute kidney injury becomes a concern. Laboratory tests reveal a rising creatinine level and decreasing glomerular filtration rate, necessitating the involvement of nephrology for potential renal replacement therapy. Additionally, repeat chest imaging shows progression of the pleural effusion, and a decision is made to perform another thoracentesis to relieve respiratory compromise and improve oxygenation.

The nursing team plays a crucial role in coordinating care, ensuring frequent vital sign checks, continuous monitoring of oxygen saturation, and assessment of fluid balance. The evolving clinical picture demands a dynamic approach, with regular interdisciplinary discussions to refine the treatment plan and address the patient's complex needs. As the team navigates these challenges, they remain vigilant for further complications, ready to adapt their strategy to optimize the patient's chances of recovery and prevent further deterioration.

Section 5

As the clinical team continues to manage the patient's condition, a new complication emerges that requires immediate attention. Fresh laboratory results indicate a significant drop in her platelet count, now at 85,000/μL, suggestive of thrombocytopenia. This development raises concerns about potential disseminated intravascular coagulation (DIC), a known complication in septic patients. The nursing team notes petechiae on the patient's arms and legs during a comprehensive skin assessment, further corroborating the suspicion of a coagulation disorder. In response, the medical team orders a coagulation profile, which reveals prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), alongside a decreased fibrinogen level, confirming the diagnosis of early-stage DIC.

Given these findings, the treatment plan is adjusted to address this new complication. The patient is started on fresh frozen plasma and platelet transfusions to manage her coagulation abnormalities and mitigate bleeding risks. The nursing team is integral in administering these blood products and monitoring for any adverse reactions. They also increase vigilance for signs of further bleeding or bruising, ensuring that any new changes in the patient's condition are promptly reported to the healthcare providers. This involves regular reassessment of vital signs, which now include a slightly elevated heart rate of 110 bpm, potentially indicating compensatory tachycardia due to ongoing hemodynamic instability.

Interdisciplinary collaboration becomes even more critical as the team explores the underlying causes of the patient's deteriorating condition. Close communication with hematology and infectious disease specialists is essential to refine the therapeutic approach and anticipate potential challenges. The focus remains on stabilizing the patient's coagulation status while continuing to manage her septic shock and respiratory compromise. As the team navigates these complexities, they prepare for the possibility of further interventions, such as additional blood product administration or escalation of supportive care measures, to improve the patient's overall prognosis and prevent progression to severe multi-organ dysfunction.