Presentation of Patient and Problem
Mrs. Claire, a 63-year-old woman, comes to the emergency department with various concerns, including breathing problems, cough, and fever of 39.5°C that has persisted in the last four days. She reports feeling weak and tired and has noticed that her cough has yellowish-green mucus. According to John Hopkins Medicine (2024), the most common indicator of pneumonia is a cough with yellowish-green mucus. As such, the immediate step I would undertake as a nurse caring for Mrs. Claire is to conduct a thorough assessment to understand her respiratory rate and lung sound auscultation. Also, as part of the assessment, I will monitor her vital signs, including her blood pressure, oxygen saturation, heart rate, and temperature. Besides, I will monitor her fluid levels and offer intravenous fluids if her fluid volume is inadequate.
Pathophysiology
Pneumonia is an infection that aggravates the air sacs in the lungs. Pus or fluid may fill the air sacs, leading to a cough with pus or phlegm, chills, fever, and breathing problems. Notably, pneumonia is caused by various organisms, such as fungi, viruses, and bacteria. Pneumonia can either be mild or life-threatening. Mainly, infants, toddlers, individuals with compromised immune systems, persons with preexisting health issues, and people older than age 65 are the most vulnerable patient populations (Johns Hopkins Medicine, 2024). The indicators of pneumonia are considered either mild or severe according to aspects like age, general health and the kind of germ causing the infection. Usually, mild signs and symptoms are similar to flu or cold symptoms. The signs and symptoms of pneumonia are fatigue, cough with phlegm, mental awareness changes, chest pain when breathing or coughing, sweating, fever, chills, diarrhea, vomiting, nausea and low body temperature (Mayo Clinic, 2024). Nevertheless, the most common indicator of pneumonia is a cough with either bloody, yellow, or green mucus.
The causes of pneumonia are numerous and they are classified by the reason. The primary forms of pneumonia include bacterial, viral, mycoplasma, and other pneumonias. Notably, bacterial pneumonia is caused by several bacteria, and the most popular is Streptococcus pneumoniae (Johns Hopkins Medicine, 2024). The disease happens when the body is weakened by impaired immunity, old age, poor nutrition, and disease. Bacteria pneumonia affects all patient populations, but those who smoke cigarettes and abuse alcohol have a weakened immune system, had surgery, viral infection, and a weakened immune system. Viral pneumonia is caused by viruses such as influenza, which is responsible for about one-third of all pneumonia infections. Moreover, mycoplasma pneumoniae is known as atypical pneumonia and is caused by mycoplasma pneumoniae bacterium (Johns Hopkins Medicine, 2024). It causes mild and widespread pneumonia that impacts age populations. Lastly, other pneumonias are less common, and they are caused by infections like fungi.
Pneumonia treatment relies on the kind of pneumonia where antibiotics are used to manage bacterial pneumonia, while viral pneumonia can get better on its own. Other forms of treatment include oxygen therapy, rest, fluid intake, healthy nutrition, and drugs for fever, cough, and pain management (Mayo Clinic, 2024). Most patients with pneumonia respond well to treatment. However, the disease can result in severe lung issues.
History
Mrs. Claire has a medical history of high blood pressure and type 2 diabetes, which have been managed by medications. Mrs. Claire has been taking diuretics to assist the kidneys to excrete water and sodium from the body, ultimately, lowering blood pressure and prazosin to relax various muscles and lowering blood pressure. Besides, she has been taking insulin to manage type 2 diabetes and acquire optimal blood sugar management.
Nursing Physical Assessment
Mrs. Claire’s blood pressure was 140/85mm Hg; her temperature was 39.5°C; her heart rate was 103 beats/min; her respiration rate was 25 breaths/min; and her oxygen saturation was 95%. The chest auscultation indicated coarse hisses and reduced breathing sounds in the left lower lung. According to Murali et al. (2022), auscultation of the chest is done to identify the breathing sound frequency in the six regions. However, no wheezing is discovered. The lab tests revealed that she had an elevated white blood cell count of 15000/mm, and the C-reactive protein increased to 42mg/L. Lastly, the ordered chest X-ray shows patchy amalgamation in the right lung’s lower lobe, congruent with pneumonia.
Related Treatments
According to Mayo Clinic (2024), pneumonia treatment involves managing the infection and averting complications. The therapy relies on the type and seriousness of pneumonia, age, and general health. Mainly, antibiotics will be prescribed to manage bacterial pneumonia and fever, and pain relievers such as ibuprofen and aspirin will be given.
Nursing Diagnosis & Patient Goals
The main problem for Mrs. Claire is breathing problems, which adversely impact her ability to retain sufficient gas exchange. As such, the nursing diagnosis indicated that she had insufficient gas exchange associated with pneumonia, indicated by patches in the chest X-ray, decreased breath sounds, fever, cough, and breathing problems. Some nursing interventions include offering supplemental oxygen to sustain oxygen saturation and administering recommended antibiotics to manage pneumonia and alleviate respiratory signs (Johns Hopkins Medicine, 2024). The goals of the nurse when treating Mrs. Claire include promoting her respiratory status and managing her breathing problems. Also another objective is to accomplish adequate oxygen and teach Mrs. Claire self-care methods. Moreover, the desired changes for the patient include resolving the pneumonia infection, alleviating fever and cough, and restoring normal breathing. (Author, year of publication).
Nursing Interventions
Oxygen therapy is the most suitable intervention to correct Mrs. Claire’s breathing problems and promote her respiratory status. According to Mayo Clinic (2024), offering supplemental oxygen to patients helps resolve breathing issues in clients with pneumonia. The next intervention is patient education, where Mrs. Claire will be taught about pneumonia, its treatment, and self-care strategies. According to Torres et al. (2021), patient education is a critical effort that helps healthcare professionals share significant health information, which promotes positive results.
Evaluation
After offering oxygen therapy to Mrs. Claire, the oxygen saturation levels improved such that they were maintained at 92%. Besides, the intervention was successful because the respiratory rate was reduced, and Mrs. Claire’s overall health improved as the fever was within normal ranges (Mayo Clinic, 2024).
Recommendations
The nurse and Mrs. Claire should collaborate to ensure continuous recovery and improvement. This is because a trustworthy relationship will guarantee that Mrs. Claire understands the significance of medication adherence, particularly in managing her diabetes and taking the right doses of antibiotics to treat pneumonia (Lampus & Wuisan, 2024). Also, their trusted relationship will make it easy for follow-up efforts. Here, the nurse can monitor Mrs. Claire’s condition to determine her progress, check for complications, and select the treatment’s success.
References
Johns Hopkins Medicine. (2024). Pneumonia. Retrieved from Johns Hopkins Medicine: https://www.hopkinsmedicine.org/health/conditions-and-diseases/pneumonia
Mayo Clinic. (2024). Pneumonia. Retrieved from Mayo Clinic: https://www.mayoclinic.org/diseases-conditions/pneumonia/symptoms-causes/syc-20354204
Murali, A., Prakash, A., Dixit, R., Juneja, M., & Kumar, N. (2022). Lung ultrasound for evaluation of dyspnea: a pictorial. https://accjournal.org/upload/pdf/acc-2022-00780.pdf
Lampus, N. S., & Wuisan, D. S. (2024). Correlation between Doctor-Patient Communication with Patient Satisfaction and Loyalty. Medical Scope Journal, 6(2), 149-158. https://doi.org/10.35790/msj.v6i2.53161
Torres, A., Cilloniz, C., Niederman, M. S., Menendez, R., Chalmers, J. D., Wunderink, R. G., & van der Poll, T. (2021). Pneumonia. Nature Reviews Disease Primers, 7(1), 1-28. https://doi.org/10.1038/s41572-021-00259-0
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