Case Study: The Management of Pneumonia of a 65 Year Old Woman for BSc Nursing

Patient Overview

Name: Mrs. Judith Harper

Age: 65 years

Medical History: Has type 2 diabetes mellitus, hypertension and history of smoking (20 pack years).

Presenting Symptoms: Cough with sputum production, fever, breathlessness, and chest pain of 5 days duration.

Initial Assessment

Mrs. Judith Harper was presented to the emergency department having difficulty breathing, persistent cough with expectoration, and pain in the chest with breathing (pleuritic). A low-grade temperature was reported by her daughter at home, who recorded 38.2°C. At the time of arrival Mrs. Harper had the following vitals;

Temperature: 38.5°C

Heart Rate: 110 bpm

RespirATORY Rate: 24 breaths per minute

Blood Pressure: 140/90 mmHg

Oxygen Saturation: 88% on room air

Mrs. Harper was looking severely ill and was in respiratory distress. Auscultation of the lungs revealed crackles of the right lower lobe accompanied by dullness to percussion which raised the possibility of pneumonia.

Medical History & Risk Factors

She is a chronic smoker, diabetic and hypertensive which makes Mrs. Harper more susceptible to develop pneumonia, specifically CAP. Smoking functionally damages the cilia in the airways and therefore the mucociliary clearance which facilitates the colonization of the airways by pathogens. Diabetes also damages the imunology functioning,

Diagnosis

Chest X-ray:

A right lower lobe consolidation was identified, hence confirming the diagnosis of pneumonia.

Laboratory Tests:

Complete Blood Count (CBC): High leukocyte amount of 16,000 cells/µL that correlates with an active state of infection.

C-protein (CRP): High of 120mg/L and more still supporting variation of CRP during sick.

Arterial Blood Gases (ABG): Identified respiratory alkalosis with PaO2 of 60 mm of Hg in room air.

Sputum Culture

During this hospitalization, a sputum culture was collected in order to identify the organism. Streptococcus pneumoniae is the more recurrent pathogen in CA pneumonia, however other bacterial infection is to be ruled out.

Interventions by the Nurse

Oxygen Therapy:

Mrs. Harper was specifically placed on 2L of oxygen via nasal cannula in order to enhance the patient’s oxygen saturation which improved to 93%.

Antib

iotic Therapy:

Antibiotics especially the beta lactams and the macrolides Ceftriaxone and Azithromycin were started as empirical therapy guess while waiting for the culture results. Timely administration of antibiotics is vital in the treatment of pneumonia for a good prognosis.

Hydration & Nutrition:

on and Since Mrs. Harper had poor oral intake because of feeling ill, she was given IV fluids in order to sustain hydration. Adequate hydration and nutrition are very important in the recovery process from pneumonia.

Monitor Vital Signs and Oxygenation: