Upload
evan
View
71
Download
0
Tags:
Embed Size (px)
DESCRIPTION
Diagnosis:. Aspiration Pneumonia. Case Information. 27 year old, male Admitted with uncontrollable fever Transferred from long term care facility Hx . of gunshot wound to left chest resulting in cardiac arrest Developed hypoxic encephalopathy Has tracheostomy and gastronomy tubes - PowerPoint PPT Presentation
Citation preview
ASPIRATION PNEUMONIADiagnosis:
Chelsea, Elisha, Jessica, Lisa, Morgan
Chelsea, Elisha, Jessica, Lisa, Morgan
Case Information
27 year old, male Admitted with uncontrollable fever Transferred from long term care facility Hx. of gunshot wound to left chest
resulting in cardiac arrest Developed hypoxic encephalopathy Has tracheostomy and gastronomy tubes Hx. of MRSA Devoted family
Chelsea, Elisha, Jessica, Lisa, Morgan
Assessment
Thin, cachetic man Moderate respiratory distress Unresponsive to voice, touch, painful stimuli VS: T=40°C, P=120, R=30, SpO₂=90% Crackles and scattered wheezes in upper left lobe Serum albumin 2.8g/dl WBC count 1.8x10⁹/L Sputum specimen thick, green and foul smelling; cultures pending ABG: pH 7.29, PaO₂80mmHg, PaCO₂40mmHg, Bicarbonate 16
mEq/L Stool culture positive Clostridium difficile Chest x-ray: infiltrate in left upper lobe; no pleural effusions noted
Chelsea, Elisha, Jessica, Lisa, Morgan
Aspiration PneumoniaWhat is it?
Chelsea, Elisha, Jessica, Lisa, Morgan
Aspiration Pneumonia Pathophysiology Aspiration pneumonia is caused by the abnormal entry
of secretions or substances into lower airway. These substances them provide an environment for bacteria to grow. There are four stages of aspiration pneumonia pathophysiology and they are as follows:
Congestion: when bacteria reach alveoli the organisms multiply and fluid flows out of the alveoli
Red hepatization: massive dilation of capillaries and alveoli are filled with bacteria, organisms, neutrophils, red blood cells and fibrin
Grey hepatization: blood flow decreases and leukocytes and fibrin accumulate in the affected part of the lung
Resolution: complete resolution and healing occur if there are no complications
Chelsea, Elisha, Jessica, Lisa, Morgan
Hypoxic Encephalopathy
What is it?
Chelsea, Elisha, Jessica, Lisa, Morgan
Hypoxic Ecephalopathy Pathophysiology Hypoxic encephalopathy is a condition in which the entire
brain does not receive enough oxygen, but isn’t completely deprived
Within as little as five minutes of oxygen deprivation, brain cells can begin dying.
The disease can also cause long-term damage including: Mental retardation Delayed development Seizures Cerebral palsy
Severe oxygen deprivation can result in: Coma Lack of brain stem reflexes (breathing and responding to light) Only blood pressure and heart function reflexes are functioning
Chelsea, Elisha, Jessica, Lisa, Morgan
Clostridium difficileWhat is it?
Chelsea, Elisha, Jessica, Lisa, Morgan
Clostridium Difficile Pathophysiology
Most serious cause of antibiotic associated diarrhea Most common symptoms are watery diarrhea, fever, and abdominal pain or
tenderness When the C diff bacteria, that normally reside in the body become overgrown,
it can cause severe infection of the colon, colitis, and eradication of the normal gut flora by antibiotics
The overgrowth is harmful because the bacterium releases toxins that can cause bloating, constipation, diarrhea, and abdominal pain
Can be flu- like symptoms Discontinuation of the causative antibiotic is often curative If it becomes more serious, treatment by oral admin of metronidazole or
vancomycin Typical antibiotics that cause C diff are: ampicillin, amoxicillin, and
cephalosporins. Some less common causative antibiotics are: penicillin, erythromycin,
trimethoprim, and quinolones Some that rarely cause C diff are: tetracycline, metronidazole (Flagyl), and
gentamicin
Chelsea, Elisha, Jessica, Lisa, Morgan
Tracheostomy Tube
A tube inserted into the trachea to allow for a patent airway.
It is inserted below the larynx and as a result the vocal chords no longer function
Chelsea, Elisha, Jessica, Lisa, Morgan
Gastrostomy Tube
A tube inserted directly into the stomach
Nutrition is administered totally through this tube. The patient takes nothing by mouth
A P.E.G tube is a Percutaneous Endoscopic Gastronomy tube. This refers to how the tube is inserted
Chelsea, Elisha, Jessica, Lisa, Morgan
What does it all mean?
Lab Values
Chelsea, Elisha, Jessica, Lisa, Morgan
Lab Values
Serum Albumin
Pt. Value: 2.8 g/dL Normal Range: 3.4-5.4 g/dL
Protein in highest concentrations in plasma – main transport
protein Values affected by synthesis, distribution, and degradation
processes Decreased levels maybe due to inadequate production, excessive
loss To determine if a patient has liver, kidney disease or if not
enough protein is being absorbed by the body Indicates nutritional status, hydration, chronic disease
Chelsea, Elisha, Jessica, Lisa, Morgan
Lab Values
White Blood Cells
Pt. Value: 18000 µL (18 x 109/L) Normal Range: 3.8-10.8 x 109/L
Neutrophils, eosinophils, basophils, monocytes,
lymphocytes produced in bone marrow – body’s defense system
Life span of cell is 13-20 days, old cells destroyed by lymph system and excreted in feces
Increased count: leukocytosis Decreased count: leucopenia
Chelsea, Elisha, Jessica, Lisa, Morgan
Lab Values
Arterial Blood Gas Evaluates respiratory function Determines: acid-base balance, if patient is in a
respiratory or metabolic imbalance
Pt. pH: 7.29 Normal Range: 7.35-7.45
Changes in ratios of free H+ to bicarbonate result in compensatory response from: lungs (respiratory) or kidneys (metabolic)
Chelsea, Elisha, Jessica, Lisa, Morgan
Lab Values
Arterial Blood Gas
Pt. PaO2: 80 mmHg Normal Range: 80-95 mmHg
Used to calculate hemoglobin saturation and availability of O2 for critical organs
With PaCO2, used to measure O2 gradient of alveolar-arterial gradient indicating effectiveness of gas exchange
Chelsea, Elisha, Jessica, Lisa, Morgan
Lab Values
Arterial Blood Gas
Pt. PaCO2: 40 mmHg Normal Range: 35-45mmHg
Important indicator of ventilation: Conditions that interfere with normal breathing causes CO2
to be retained in blood Conditions that increase breathing rate will cause CO2 to be
removed from alveoli more rapidly than it is produced resulting in alkaline pH
Level controlled primarily by lungs therefore is respiratory component of acid base balance
Chelsea, Elisha, Jessica, Lisa, Morgan
Arterial Blood Gas
Acid-Base Disturban
ce
pH pCO2 pO2 HCO3-
Respiratory Acidosis
Uncompensated Decreased Increased Normal NormalCompensated Normal Increased Increased IncreasedRespiratory
AlkalosisUncompensated Increased Decreased Normal NormalCompensated Normal Decreased Decreased Decreased
Metabolic Acidosis
Uncompensated Decreased Normal Decreased DecreasedCompensated Normal Decreased Decreased Decreased
Metabolic Alkalosis
Uncompensated Increased Normal Increased IncreasedCompensated Normal Increased Increased Increased
Metabolic Together Respiratory Opposite
Chelsea, Elisha, Jessica, Lisa, Morgan
NURSING DIAGNOSIS
Chelsea, Elisha, Jessica, Lisa, Morgan
Impaired gas exchange r/t to collection of mucus in airways and inflammation of airways and alveoli Objective Data
PaO2 80 mmHg Pa CO2 40mmHg Respiratory Rate of 30 Heart Rate of 120
Chelsea, Elisha, Jessica, Lisa, Morgan
Impaired gas exchange r/t to collection of mucus in airways and inflammation of airways and alveoli Interventions
Assess respirations Monitor changes in vital signs Assess skin for cyanosis Monitor ABGs and oxygen saturation Maintain oxygen administration device as ordered Anticipate need for intubation if condition
worsens Expected Outcomes
Patient maintains optimal gas exchange as evidenced by eupnea and normal ABGs
Chelsea, Elisha, Jessica, Lisa, Morgan
Ineffective airway clearance r/t to increased sputum due to pneumonia Objective Data
Respiratory Rate 30 O2 Saturation 90% Chest auscultation revealed crackles and scattered
wheezes in the left upper lobe Chest x-ray; infiltrate in left upper lobe
Interventions Assess respiratory movements and use of accessory
muscles Assess sputum color, amount, and odor and report changes Auscultate lung sounds Monitor pulse oximetry Monitor chest x-ray reports
Chelsea, Elisha, Jessica, Lisa, Morgan
Ineffective airway clearance r/t to increased sputum due to pneumonia Interventions
Sit the patient up in bed Maintain adequate hydration Use humidity Assist with oral pharynx suctioning if necessary Provide oral care Consult respiratory therapist for chest
physiotherapy and nebulizer treatments Expected Outcomes
Patient airway is free of secretions as evidenced by eupnea and clear lung sounds
Chelsea, Elisha, Jessica, Lisa, Morgan
Infection r/t to aspiration from tracheotomy Objective Data
Temperature 40˚C O2 Saturation 90% Crackles and scattered wheezes heard throughout
lung fields WBC 18000/μl Sputum specimen: thick, green colored, foul smelling Chest x-ray: infiltrate in left upper lobe
Interventions Assess vital signs, monitor temp Obtain sputum for culture and sensitivity Monitor lung sounds
Chelsea, Elisha, Jessica, Lisa, Morgan
Infection r/t to aspiration from tracheotomy
Interventions Monitor WBC Assess hydration Monitor pulse oximetry Monitor chest x-ray reports Administer antimicrobial agents Use appropriate therapy for elevated temperatures;
antipyretics, cold therapy Isolate patients as necessary after review of culture and
sensitivity Expected Outcomes
Patient experiences improvement in infection as evidenced by normo-thermia, normal WBC count & negative sputum culture report on repeat culture
Chelsea, Elisha, Jessica, Lisa, Morgan
Imbalanced Nutrition: less than body requirements r/t gastronomy tube, inability to swallow and diarrhea r/t C.Difficile
Objective Data Cachetic appearance G-Tube in situ Positive Clostridium Difficile stool culture
Nursing Interventions Ensure feeding schedule is maintained Ensure continued support from Registered
Dietician Check placement and patency of tube Measure amount of feeding exactly
Chelsea, Elisha, Jessica, Lisa, Morgan
Imbalanced Nutrition: less than body requirements r/t gastronomy tube, inability to swallow and diarrhea r/t C.Difficile
Interventions Monitor lab values (electrolyte levels,
hematocrit, hemoglobin, blood glucose, and total protien)
Treat C.Difficile appropriately Expected Outcomes
Pt. will attain an increased nutrition status as evidenced by body weight will be within 10% of ideal body weight for his age and height
Chelsea, Elisha, Jessica, Lisa, Morgan
Infection r/t antibiotics
Objective Data History of MRSA in sputum Admitted because of uncontrollable fever Stool culture positive for Clostridium difficile WBC count 18,000/ul (18 x 109/L) (normal 3.8-10.8 x 109/L) Temperature 1040F (40oC)
Interventions Note risk factors causing the infection (prolonged
antibiotic use, weakened immune system, other infections Stress proper hand hygiene by all caregivers and family
members Use isolation precautions (gown and glove for c.diff but if
MRSA is in sputum then everyone needs to mask as well)
Chelsea, Elisha, Jessica, Lisa, Morgan
Infection r/t antibiotics
Interventions Provide information such as pamphlets or handouts to family on
the pathophysiology of c diff and ways to reduce spread of infection
Maintain sterile technique for all invasive procedures Encourage position changes to prevent any further complications Administer antibiotics as indicated
Expected Outcomes Family of patient will verbalize the understanding of the use of
disease precautions and the importance of them during the first day of care.
Family will identify interventions to prevent the spread of infection during the first couple days on the unit
Family will demonstrate techniques, lifestyle changes to promote safe environment upon discharge
Chelsea, Elisha, Jessica, Lisa, Morgan
Risk for deficient fluid volume r/t C.Diff Objective Data
Stool culture positive for C.Diff Interventions
Monitor urine output, intake, and record on data sheet, and observe color and odor of urine
Weigh daily (same time and scale) Evaluate lab tests such as: electrolytes, blood
urea, creatinine, total protein) Evaluate nutritional status Assess vital signs (temp, pulse, and resps, BP) Watch for changes in usual function
Chelsea, Elisha, Jessica, Lisa, Morgan
Risk for deficient fluid volume r/t C.Diff Interventions
Administer fluids and electrolytes as indicated Educate patient and family on factors related to
occurrence of deficit Modify care plan if patient is not getting the nutrients he
needs Expected Outcomes
Patient will maintain stable vital signs, urine output, skin turgor, and moist mucous membranes throughout admission
Will verbalize understanding of causative factors and purpose of interventions when LOC is appropriate
Patient will demonstrate behaviors to monitor and correct this deficit
Chelsea, Elisha, Jessica, Lisa, Morgan
Risk for impaired skin integrity r/t C.diff Objective Data
Stool culture positive for c.diff Interventions
Assess circulation and sensation Watch for redness or non blanching skin around
bony prominences Teach patient the importance of good peri-care Note any odors coming from wounds Inspect skin on a daily basis Keep perineum is clean and dry, and teach
client how to manage incontinence
Chelsea, Elisha, Jessica, Lisa, Morgan
Risk for impaired skin integrity r/t C.diff Interventions
Maintain cleanliness of bedding so pt is not soiled for a prolonged amount of time
Reposition client q2h so skin breakdown will not occur Prevent any shearing or tearing of skin if transferring or from
movement Assess client psychological status for risks of feeling helpless
Expected Outcomes Patient will participate in preventative measures and
treatment program while in care Patient will maintain optimal nutrition and physical well
being while in care Patient will verbalize feelings of increased self- esteem and
ability to manage situation upon discharge
Chelsea, Elisha, Jessica, Lisa, Morgan
Discussion Questions
What types of infectious disease precautions should be taken related to Sam’s hospitalization? To prevent to spread of any disease in a facility, staff
should practice scrupulous hand hygiene Patients with diarrheal illnesses should be isolated. Gowns & gloves should be worn by all personnel
attending to the infected patients. With the possibility of MRSA, masks should also be
worn Linens should be disinfected. Surfaces potentially
infected be clostridium spores should be treated with bleach
Personal care items should not be shared or reused
Chelsea, Elisha, Jessica, Lisa, Morgan
Discussion Questions
What clinical manifestations of aspiration pneumonia did Sam exhibit? Explain their significance. Temperature of 40°C Crackles and scattered wheezes in left, upper
lobe X-ray showed infiltrate in left, upper lobe Respiratory rate of 30 SpO₂ of 90% Green, thick, fowl smelling sputum Elevated WBC
Chelsea, Elisha, Jessica, Lisa, Morgan
Discussion Questions
What antibiotic medication is likely to be prescribed? Patients with mild to moderate c diff.
typically improve with oral metronidazole or vancomycin.
More severely infected patients may need infusions of vancomycin directly into the GI tract.
Metronidazole is also highly effective in treating lower respiratory tract infections such as pneumonia
Chelsea, Elisha, Jessica, Lisa, Morgan
Discussion Questions
What other clinical issues need to be addressed regarding his care? Skincare – risk for breakdown Hydration – increased requirement r/t
diarrhea Oral care deficit r/t tubing, decreases
fluid intake Impaired coping - Family coping Changed may be required in long term
facility
Chelsea, Elisha, Jessica, Lisa, Morgan
Discussion Questions
What family interventions would you initiate? Education re: good hand hygiene,
infection control precautions (isolation). This will limit the spread is C Diff.
The family should avoid visiting while they are sick
Family support systems – Initiate contact with support group for children with brain injury
Respite care Stress management techniques
Chelsea, Elisha, Jessica, Lisa, Morgan