265 Med Surg Hesi Case Study
Arterial oxygen saturation (SaO2 or SpO2) does not report the partial pressure of oxygen (PaO2) although arterial oxygen saturation is a function of PaO2. PaO2, determined through analysis of arterial blood obtained via an arterial line or arterial puncture, refers to the force exerted by oxygen in arterial blood. The greater the force exerted by oxygen in arterial blood, the more oxygen that is bound to hemoglobin. The relationship between PaO2 and SaO2, represented by the oxyhemoglobin dissociation curve, is important. With PaO2 tensions of 60 mm Hg and above, hemoglobin is at least 90% saturated with oxygen and the amount of oxygen available to tissues is great.Low PaO2 tensions (below 60 mm Hg), however, reflect a severe decrease in the amount of oxygen carried in the blood and cause significant drops in SaO2, resulting in severely limited supplies of oxygen available to tissues.Clinically, when SaO2 levels are low, the client is severely deprived of oxygen. Mr. Hannigan's SpO2 on room air is 90%. This is a low reading, indicating inadequate oxygenation.In pneumonia, bacterial growth causes alveolar inflammation and consolidation. These reduce the alveolar area available for ventilation and gas exchange, and hypoxemia results. Mr. Hannigan's chest x-ray in the healthcare provider's (HCP) office showed pulmonary infiltrates in the right lower lobe. This is consistent with pneumonia. Infiltrates are abnormal fluid and cells seen in patches in an affected area. When abnormal cells and fluid are more concentrated (consolidation), airflow is ultimately more restricted, resulting in impaired gas exchange. The respiratory therapist is notified about the HCP's prescription for drawing arterial blood gases (ABGs) on Mr. Hannigan. Which actions should be implemented after the specimen is drawn?
Apply direct pressure to the puncture site Because of the potential for hemorrhage from an arterial puncture site, pressure should be applied to the site for at least five minutes (longer for clients on anticoagulants). Agency protocols may vary. Arrange for immediate transport of the specimen to the laboratory Freshly oxygenated blood is needed for accurate blood gas analysis. Immediate transport of the specimen (in ice) to the laboratory is necessary, and will decrease the chance that air might enter the specimen. Inaccurate results can be obtained if the specimen is contaminated with air. Notifying the laboratory when a blood gas specimen is being sent will ensure that the proper laboratory equipment is ready to analyze the specimen when it arrives. If the client is receiving oxygen, details of oxygen therapy should be provided with the laboratory specimen. Ensure an airtight seal for the blood specimen container An airtight seal is needed to prevent air from entering the blood sample. Inaccurate results can be obtained if the specimen is contaminated with air. After a blood specimen is obtained, an airtight seal can be accomplished by taking the needle off the syringe, eliminating air bubbles from the specimen, and putting the syringe cap on. This is followed by rolling the syringe between hands to insure mixing of blood with the heparin used to coat the syringe before puncture. Heparin prevents the blood from clotting.
Mr. Hannigan's white blood cell count is elevated at 13,000/mm3, secondary to infection. In response to invasion of pathogens, leukocytes are mobilized to contain invading foreign matter and prevent spread.Overwhelming infection may deplete leukocytes, resulting in a low white blood cell count. White blood cell count may remain normal in older persons, because of decreased immune system response. You work on Mr. Hannigan's plan of care. Which nursing measures should you incorporate into Mr. Hannigan's care?
Encourage oral fluids Oral fluids should be encouraged. Fluid intake should be increased to help liquefy respiratory secretions and make them easier to expectorate. Extra fluids are indicated to prevent crystalluria, a side effect of Levaquin (levofloxacin). A minimum intake of 2000 mL of fluid is recommended. Use of side rails Mr. Hannigan is confused. Side rails should prevent Mr. Hannigan from falling out of bed and injuring himself. Agency protocols for use of side rails should be followed. Ongoing assessment of Mr. Hannigan's mental status and need for side rails is indicated. Bed in low position Mr. Hannigan is confused. Keeping his bed in the low position should help prevent injury if he tries to get out of bed. Assist with activities of daily living Mr. Hannigan's oxygenation is compromised. Activity should be restricted so that oxygen is available for major organ function and not used for unnecessary activity. Mr. Hannigan should receive assistance with activities of daily living and he should be allowed frequent rest periods. As oxygenation improves, activity tolerance should improve. Frequent position changes Frequent position changes are indicated to help mobilize respiratory secretions. Frequent position changes will improve circulation and help prevent pressure ulcers and deep vein thrombosis, secondary to immobility. Ambulation should resume as soon as possible, when oxygenation is adequate.
Mr. Hannigan has right lower lobe pneumonia. It is probable that oxygenation will be best when he rests in left lateral position.The best ventilation, perfusion, and gas exchange usually occurs in dependent areas of the lungs. Positions that place the healthiest lung areas in the most dependent position should result in optimal oxygenation. Positioning Mr. Hannigan on his unaffected left side (healthiest lung area) should result in optimal oxygenation. Positioning him on his back (with the head of bed elevated) and his right side are acceptable. Checking Mr. Hannigan's SpO2 when he is in different positions will verify the best position for him. Mr. Hannigan is receiving the broad-spectrum antiinfective drug levofloxacin. Levofloxacin is active against Strep pneumonia. Based on your knowledge of the potential complications of this drug, you will be alert for which adverse effects? (Select all that apply.)
Loose, watery stools Gastrointestinal side effects that may occur include abdominal pain, constipation, diarrhea, dyspepsia, nausea and vomiting. Tendon Rupture Levfloxacin may increase the risk of tendinitis and rupture. Monitor client for tendon pain or inflammation. Photosensitivity Sun exposure can cause photosensitivity reactions so advise client to stay out of sun or wear protective clothing.
When evaluating your plan of care for Mr. Hannigan with regard to the problem of impaired gas exchange, which criteria would indicate a successful outcome?
Mr. Hannigan has a PaO2 (arterial oxygen) above 80 mm Hg A PaO2 (arterial oxygen) above 80 mm Hg is normal. It is a good indicator of adequate gas exchange at the alveoli level.
You are making room assignments for several new admissions. How do you decide which room to assign to Mr. Hannigan? Which considerations are critical for the nurse to make when assigning a room to a client with community acquired pneumonia (CAP)?
Mr. Hannigan's confusion Mr. Hannigan's confusion is an important consideration for room assignment. The fact that Mr. Hannigan is confused places him at risk for injury. An initial assessment found Mr. Hannigan to be disoriented to time, place, and person. Bed placement as close to the nurses' station as possible is important. Infection control Infection control is an important consideration for room assignment. Mr. Hannigan has pneumonia, although the specific organism responsible for infection is not known at this time. The means of transmission is not yet known. To decrease risk for hospital-acquired pneumonia or other nosocomial infections in other clients, Mr. Hannigan was assigned to a private room.
As you care for Mr. Hannigan, which intervention is the most important to implement?
Promoting oxygenation Promoting oxygenation takes priority with Mr. Hannigan. Without adequate oxygenation, hypoxemia can result in subsequent generalized tissue hypoxia.
After one hour on nasal oxygen at 2 liters per minute in the Fowler's position, Mr. Hannigan's SpO2 has improved to 95%, and he is breathing easier. The results of Mr. Hannigan's arterial blood gases, taken on admission, are available. You expect results to reflect which type of acid-base imbalance?
Respiratory alkalosis On admission, Mr. Hannigan was breathing rapidly. His increased respiratory rate was an effort to compensate for hypoxemia and take in more oxygen. An increase in the rate of breathing causes a decrease in arterial carbon dioxide levels. This can lead to respiratory alkalosis.
Community-acquired pneumonia (CAP) is often caused by the bacterium Streptococcus pneumonia (typical pneumonia). This type of pneumonia is most common among older persons and among very young children. Streptococcal pneumonia is one of the most common infectious causes of illness and death among the elderly. That is why it is recommended that older adults, ages 65 and older receive the pneumococcal vaccine.In adults, typical pneumonia is caused by streptococcus, Haemophilus influenza,Staphylococcus aureus, Group A streptococcus or Moraxella catarrhalis. Atypical is caused by Legionella, mycoplasma pneumonia, or chlamydia pneumoniae. There are different types of bacterial pneumonia (community acquired, hospital acquired, ventilator associate, healthcare associated) and each have a period of communicability, means of transmission, and type of isolation required. These vary depending on the infecting agent.The incubation period for streptococcal pneumonia is unclear but short, and the period of communicability is unknown. To prevent transmission of pneumonia, hand hygiene is critically important. Isolation precautions should be implemented in the following situations: contact precautions if colonized or infected with MRSA, VRE, or multidrug resistant gram negative organisms; droplet precautions for mycoplasma or influenza; airborne precautions in cases of pulmonary tuberculosis, varicella, measles or viral hemorrhagic fevers; and strict airborne precautions if the client has SARS. According to Centers for Disease Control (CDC) guidelines, which isolation precautions are indicated for Mr. Hannigan at this time?
Standard Precautions Centers for Disease Control (CDC) Guidelines for Isolation Precautions in Hospitals require that Standard Precautions be used with all hospitalized persons, regardless of diagnosis or presumed diagnosis. Droplet Precautions Centers for Disease Control (CDC) Guidelines for Isolation Precautions in Hospitals require that Droplet Precautions be used with persons who have suspected or known infections that are transmitted by large particle droplets, including some pneumonias. These pneumonias are contagious with coughing, sneezing, talking, and procedures requiring close contact. Usually transmission is by nasopharyngeal/respiratory secretions and/or sometimes saliva. It is possible that Mr. Hannigan has a pneumonia that will not require Droplet Precautions. However, it is prudent that Droplet Precautions be instituted to prevent transmission of infection until such time that a diagnosis suggesting otherwise is determined. Contact Precautions Centers for Disease Control (CDC) Guidelines for Isolation Precautions in Hospitals require that Contact Precautions be used with persons who have suspected or known infections that can be transmitted by direct (personal) or indirect (environmental surfaces) contact. Some pneumonias spread easily through direct contact with infected persons or indirect contact with contaminated objects or surfaces. For these pneumonias, transmission is usually by nasopharyngeal/respiratory secretions. It is possible that Mr. Hannigan has a pneumonia that will not require Contact Precautions. However, it is prudent that Contact Precautions be instituted to prevent transmission of infection until such time that a diagnosis suggesting otherwise is determined.
Mr. Hannigan is now breathing much easier and he is no longer confused. SpO2 on nasal oxygen at 2 liters per minute is now 95%. However, he is complaining of chest discomfort, especially with coughing. His coughing has increased, and mucous is present. How can the nurse best alleviate Mr. Hannigan's discomfort?
Suggest that acetaminophen be prescribed to alleviate chest discomfort An analgesic such as acetaminophen should reduce Mr. Hannigan's chest discomfort without suppressing his cough and gag reflexes. Cough and gag reflexes are needed to expectorate secretions and avoid aspiration. Sedatives and narcotic analgesics suppress these reflexes. Restriction of chest movement with a chest binder would limit airflow and increase hypoxia, predisposing Mr. Hannigan to more serious respiratory complications. Mr. Hannigan needs full lung expansion to insure maximum lung inflation and optimal gas exchange.
Mr. Hannigan is resting comfortably at the end of your shift.Two days later, when you return to work, Mr. Hannigan's condition has dramatically improved. His cough is subsiding, SpO2 on room air is maintained above 95%, and he is breathing easier. A diagnosis of streptococcal pneumonia was confirmed by gram stain, and susceptibility to levofloxacin was established.Transmission-based precautions are no longer in effect. Streptococcal pneumonia is no longer communicable after 24 hours on antibiotics.Mr. Hannigan is tolerating food and fluids. Levofloxacin is now being given orally. Mr. Hannigan will be discharged very soon. Which discharge instructions are indicated? Mr. Hannigan is discharged free of respiratory distress, after three days of hospitalization.
Take frequent rest periods as needed Recovery from pneumonia takes time. The disease process depletes the body of energy. Fatigue may persist for several weeks. Frequent rest periods are indicated. Drink lots of fluid each day Fluid intake of 2000-3000 mL per day should continue to help liquefy and loosen respiratory secretions and avoid crystalluria, a possible side effect of levofloxacin therapy.
For clients on droplet precautions and/or contact precautions, a private room is recommended. Clients known to have infection with the same organism may share a room (cohorting), if a private room is not possible.Given the availability of a private room close to the nurses' station, it was assigned to Mr. Hannigan. Standard precautions, droplet precautions, and contact precautions apply for Mr. Hannigan. Besides a private room, which of the following infection control requirements are indicated?
Wear a mask with close contact When providing close-contact (within three feet) direct care with clients on droplet precautions, the health care provider should wear a face mask. Often, this means wearing a mask when in the client's room. Wear a gown when assisting Mr. Hannigan with bathing A gown should be worn when assisting Mr. Hannigan with bathing. A gown is required with substantial physical contact as part of contact precautions. Client-care activities that might involve splashes of body fluids or secretions require a gown as part of standard precautions. Wear gloves when handling tissues containing sputum Gloves should be worn when contaminated tissues are touched. As part of standard precautions, gloves are worn when contact with body fluids or secretions is possible. Gloves are worn at all times in Mr. Hannigan's room as part of contact precautions.
You begin your assessment of Mr. Hannigan.You obtain a pulse oximetry reading of 90% on room air. The nurse monitors the pulse oximetry to assess for which value?
arterial oxygen saturation Pulse oximetry measures arterial oxygen saturation, the amount of hemoglobin that is saturated with oxygen. Oxyhemoglobin releases oxygen to tissues. Arterial oxygen saturation is an indicator of tissue oxygenation. Arterial oxygen saturation readings are obtained invasively through analysis of arterial blood obtained by arterial line or arterial puncture (SaO2) OR noninvasively with the use of pulse oximetry (SpO2).
Despite being given an NSAID, acetaminophen for pain, Mr. Hannigan continues to complain of chest soreness when coughing. What action by Mr. Hannigan would you suggest to him to decrease his discomfort?
hold a pillow across his chest when coughing Splinting sore chest muscles with a pillow during coughing should lessen musculoskeletal pain experienced when coughing, without interfering with chest expansion on an ongoing basis.
Mr. Hannigan has diminished breath sounds on the right side, indicating decreased airflow. Chest movement is diminished on the same side.Dullness with percussion, and tactile fremitus with palpation, indicate lung congestion. Mr. Hannigan has an occasional cough with little mucous. Persistent, productive cough is typical with pneumonia, although cough and sputum production may be absent, especially in older persons.Mr. Hannigan is afebrile. Fever is common with pneumonia, but may be absent in older persons. Fever occurs as part of the inflammatory process aimed at fighting invasive pathogens. Blood work, including complete blood count (CBC) and blood cultures, are drawn by a lab technician.After blood is drawn, you are able obtain a sputum specimen. When blood cultures or sputum specimens are prescribed, they should be obtained before antibiotics are started. This enables identification of an organism and its susceptibility to specific antibiotic therapy.You start an IV on Mr. Hannigan, and administer his first dose of antibiotic. The timing of antibiotics is an important factor in reducing mortality in persons with community-acquired pneumonia (CAP). Studies have shown that administration of appropriate antibiotics to clients with CAP within four hours of hospital arrival is optimal for decreasing mortality rates. Positive effects from intravenous antibiotic administration can be observed as early as 4-8 hours after the first dose. You've noticed that Mr. Hannigan is restless, confused, and picks at his sheets. What cause would be suspected for these behaviors?
hypoxia Mr. Hannigan's confusion is probably due to hypoxia. Restlessness and confusion are often early signs of hypoxemia, and reflect cerebral hypoxia.
You review the rationale for Mr. Hannigan's nursing care. What is the underlying pathophysiology of pneumonia?
inflammation and/or infection of the lung The pathophysiology of pneumonia involves excess fluid in the lungs associated with an acute inflammatory process that is usually a result of infection. Microorganisms (bacteria, viruses, fungi, parasites) gain entry into the respiratory tract either by inhalation (from airborne transmission with talking, sneezing, coughing) or aspiration (secretions from the oropharynx or nasopharynx). The organisms are not successfully cleared, and they become established.
The HCP prescribes oxygen therapy. As you implement the prescription for oxygen, the therapeutic effect of the nasal oxygen will be enhanced if Mr. Hannigan:
is positioned in the Fowler's position The Fowler's position (head of bed 45 degrees or higher) promotes full lung expansion and decreases the work of breathing. It can enhance the effectiveness of oxygen therapy and help increase oxygenation. Resting his arms on an overbed table may increase Mr. Hannigan's tolerance for this position.
People who smoke are at increased risk for respiratory infections like pneumonia. Smoking irritates the lining of the lung, produces mucous, and obstructs small airways, setting up favorable conditions for microbial invasion and growth. Smoking interferes with ciliary action and clearance of mucous, allowing organisms that gain into the respiratory tract to become established and proliferate.A variety of factors increase risk for pneumonia in persons who consume large amounts of alcohol. In these persons, suppressed tracheobronchial ciliary motion, increased risk for aspiration during drinking episodes, and bone marrow suppression with reduced white blood cell count, favor the development of pneumonia.Other risk factors for CAP include the following: individuals with HIV or those who are immunocompromised, individuals on recent antibiotic therapy or resistance to antibiotics, as well as individuals with comorbidities such as asthma, cerebrovascular disease, COPD, chronic renal failure diabetes, liver disease, neoplastic disease. Older persons, like Mr. Hannigan, are at increased risk for pneumonia. Immune responses to prevent infection when exposed to microorganisms are diminished in older persons (diminished production of immunoglobulin).Infections like pneumonia may be more severe in older persons with diabetes, secondary to poor white blood cell function. Recently, Mr. Hannigan had a "cold."Any respiratory process that creates mucous and causes mucosal edema, like a viral infection (cold or influenza) or chronic lung disease (chronic bronchitis, emphysema), can interfere with clearance of organisms that find their way into the respiratory tract. Microbial invasion can subsequently lead to pneumonia. You are conducting a physical assessment of Mr. Hannigan. Which findings would the nurse expect?
lung crackles Crackles are heard when you auscultate Mr. Hannigan's lungs, and are consistent with a diagnosis of pneumonia. Crackles are abnormal sounds heard during inspiration or expiration. Crackles are a result of air movement through retained respiratory secretions in small air passages. tachypnea Tachypnea, an increased rate of breathing, is common in persons with pneumonia. With pneumonia, gas exchange is impaired. Tachypnea occurs as a compensatory measure to bring oxygen to tissues more quickly. Mr. Hannigan is tachypneic. nasal flaring Nasal flaring is common in persons with acute pneumonia. It is an effort by the body to take in as much oxygen as possible with each breath. Nasal flaring is apparent with Mr. Hannigan as he takes each breath.
hich risk factors for community acquired pneumonia does Mr. Hannigan have in his medical history?
splenectomy 10 years ago The spleen normally serves important immunologic functions, keeping the blood free of unwanted substances and infecting organisms. Individuals without a spleen are at increased risk of bacterial infection, especially those caused by Streptococcus pneumoniae, Haemophilus influenzae, and others. Mr. Hannigan received the pneumococcal vaccine (which helps prevent infection due to the bacteria Streptococcus pneumoniae) about 10 years ago, when his spleen was removed. To maintain immunity, a one-time repeat vaccination is recommended. However, Mr. Hannigan was never revaccinated.
