Old Man With Pneumonia Case Study

Question

Task: This assessment task enables you to deeply engage with the literature around the health status of an acutely ill patient. You must select a case for analysis who has experienced either shock, or acute respiratory or cardiac failure. We are looking for demonstration of a deep understanding of the applied pathophysiology that underpins the key problem experienced by the patient, and explanation of at least one management strategy provided.

Please note, that we are not looking for a great deal of detail about the patient. The information can be conveyed in one or two sentences (see the example). Institutional approval is not required as no patient details are to be included in the paper. If you wish to include test results, then you must present them in the form of your analysis, it is not sufficient to list them, as a list does not convey your interpretation and therefore does not add to the grading. For example, you could say:

The patient presented with hypotension with a mean arterial pressure of 48, hypoxic as evidenced by low oxygen saturations, acidotic as indicated by a pH value of 7.16 and carbon dioxide levels of 55. 

In terms of case selection, if you believe that you cannot think of a suitable case for review, please contact your tutor to discuss your options. Cardiovascular students may not select heart failure as a topic. Intensive care students may not discuss positive pressure ventilation. 

Examples of topics/cases for review
The topic/case does not need to be complicated. It can be as simple as

• drop in blood pressure
• a drop in oxygen saturations
• a vasovagal episode
• aspiration of gastric contents
• pneumonia
• hypertension

and so on.
Regardless of the topic area, it is your role to explain the compensatory mechanisms that are activated in response to the problem. You then link at least one management strategy to explain the related physiology.

Answer

1. Introduction
The pneumonia case study will critically discuss about the pathophysiology problems of fifty-seven-year-old gentlemen named James. He was admitted to intensive care unit (ICU) due to acute hypoxemic respiratory failure secondary to severe pneumonia (Mansour et al., 2015). James had recently been overseas for two weeks as he went to Japan and New Zealand. Prior to 21 days to admission James was all well and first developed mild symptoms just four days ago however, had rapidly deteriorated two days ago with fevers of 39.2 degrees, shivers, hypoxia, arthralgia, myalgia and ongoing shortness of breath. Since the patient has diagnosed with influenza and need some supportive care. Furthermore, this pneumonia case study will also critically analyze with acute clinical management strategy; some more test and chest X-rays will be provided to James during his deterioration in ICU and will determine whether the clinical management implementation is supported by current evident-based literature.

2. Ethical Use of Patient Healthcare Data
The patient has some responsibility ethically and is responsible to permit their data to be used in research projects. Mostly the ethical issues would arise when there is any kind of research done on the patients’ data. It is the responsibility of the patients and the healthcare department to ensure that the patient data are analyzed ethically, and external help will be taken only when needed. 

3. Pathophysiology Problem and Treatment Analysis
Usually, in the human respiratory system, the air moves through the nose of the human and passes the nasal cavity and then through the pharynx, from there to the larynx, from there to the trachea, and then to the bronchi (Luo, 2016). There is an opening to the nose called Nares. A mucous membrane along with the cilia and the capillaries of the blood is lined with the Nasal cavity. The proposed pneumonia case study illustrates that there is a cilia were some filtration of the air is performed, warmed with the help of the blood and moistened with the help of the mucous membranes. Through the pharynx, some air passes which is called the throat. (Tordoff and Williams, 2018). Usually, this path is common for the food and air to pass. Then through the larynx, the air continues to pass. A flat of tissue called the epiglottis is the visible opposite of the larynx is closed while swallowing all kinds of food to prevent entering the Alveoli. In the larynx (voice box), there is a vocal fold. The windpipe is known as the trachea connects the larynx along with the bronchial tree. The trachea has a cartilage ring to prevent the trachea from collapsing. The pneumonia case study examines that the respiratory system also has spongy lungs tissues connected with the capillaries of blood and Alveoli. When the lungs contract and expand the human body starts to breathe. There are smaller branches of bronchi through which the air is carrying these branches called Bronchiole. There are Alveolar Sacs at each end of each Bronchiole. There is capillary of blood with the Alveolar Sacs and is surrounded and contains a single layer of Alveoli cells in millions and perform the exchange of the gas. From the pharynx the oxygenated air passes when air is inhale through the nose and then it passes through the larynx, then to the trachea, then through the bronchi, and lastly through the Alveoli. The Alveoli have the oxygen which was in the air when capillaries process the fusion. The capillaries push the carbon dioxide to the Alveoli to exhale. Such a process is defined as respiration.

In the respiration process, the body cell and the atmosphere perform some exchange of gases. Multiple events evolve in it of which one is breathing. The Alveolar Sacs carry the air to the Alveoli where the exchange of gas is processed and absorbed easily (De Giacomi et al., 2018). When there is an inspiration, the Alveoli are filled with air and perform the exchange of gas between the epithelia capillary and alveoli. The inspired oxygen that is over here is the white gas, the expired carbon dioxide over here is the blue gas. When the exchange of gas is performed, the color of the red blood cell changes eventually. The capillaries have the Red blood cells adjusted to the alveolus discharge the carbon dioxide and then the oxygen is bind.

In a pneumonia case study, it was found that this pneumonia infected patient had a fatal infection and there is an inflammation in the lower respiratory track. The cause of this infection is due to the inhaled properties of a virus, bacteria, mycoplasma, and pathogens that are, otherwise known as pneumococcus streptococcus pneumonia. The infection causes an increase in the secretion of fluids which pools and accumulates in the air sacs of the lungs (Dumas et al., 2019). The lungs have an air space where excaudate is present which causes coughing, sharp chest pain, shortness of breath and a high fever which is connected with pneumonia. The similar case was observed in the patient also when he was admitted to the hospital (Dickson et al., 2017). 

The next day a report of chest x- ray showed that pneumonia is in the left upper lobe. The pneumonia case study explores that the patient was prescribed with medications of albuterol inhaler and azithromycin as he has acute hypoxemic respiratory failure, and intravenously the patient was administered with stat dose of Ceftriaxone and azithromycin and was allowed to go home (Ramos-Rossy et al., 2018). After two days, there was persistent symptom seen in the patient for which cough syrup and prednisone is prescribed for the same. The patient mentioned in the pneumonia case study was feeling exhaustive. He was having a fever that has reached 38.8°C. He was not able to sleep since he took acetaminophen and was having recurrent cough with some blood-tinged sputum along with pleuritic chest pain. When I was examining his condition, he was having dyspnea (Kazzaz et al., 2017). As a nurse, I have checked the vital signs, the blood pressure was found to be 148/72 mm Hg, the rate of the respiration was around 26 breaths per minute, the pulse rate was 88 beats per minute and the Oxygen saturation was 94%. In the left lung base and the left axillary region, there had been seen some crackles (Serota et al., 2018). The chest radiograph shows that on the left side there is a dense infiltrate.

In the chest radiograph of lateral and posteroanterior it was found that there was a severe consolidation in the left part of the upper lobe and on the right part there was a mild consolidation with a trace left pleural effusion. However, there was no lymphadenopathy.

Before the admission, a portable anteroposterior through the chest radiographs were obtained in the left lung for further opacification and the upper lobe has a predominant involvement and the right lung has worsened to multifocal consolidation in the right upper lobe (Sanz-Herrero et al., 2016).

On the third day, the doctor has initiated a Vancomycin therapy and on the fifth day, the doctor has initiated the imipenem therapy. However, by the sixth-day hypoxemia occur to the patient for which he needed 4 litters of oxygen therapy via Nasal prongs. The ?₁- antitrypsin level was around 270 mg per deciliter (Kawakami et al., 2019). The blood levels and the anion gap of the alanine aminotransferase, IgM, IgG, total bilirubin was all normal.

As per the readings developed herein pneumonia case study, for further examination the patient was taken to the ICU and was kept for two days and examination of Bronchoscopy was done that revealed a purulent secretion that has no mucous plugs. The ejection fraction of the left ventricular was found between 60 to 65 %. The sputum specimens' cultures were negative (Kushwah et al., 2018). The Echocardiography was found to be wall motion and its function was biventricular.

By the ninth day, there was a slow and steady improvement in the airway pressure which was administered to have positive bi-level. On the same day, when the trachea was intubated electively at that moment methyl-prednisolone was administered. The blood cultures found negative and the sputum cultures had grown species of candida (Park et al., 2016).

On the 10^th day, the patient has to be admitted to the ICU again. The medications that the doctor suggested mentioned in this pneumonia case study to be given to the patient were the intravenous infusions of norepinephrine, fentanyl and midazolam also along with that moxifloxacin, vecuronium, vancomycin, imipenem, ondansetron, sodium succinate, acetaminophen, pantoprazole, enoxaparin, ondansetron, albuletrol, nystatin suspension, and fluticasone nasal spray. The patient was given a vaccination for influenza and also, he was provided indomethacin for having gout. However, there was no symptom of allergies found in his body during the administration of medications. When he was under my observation, he told me about himself, where he used to live and work. He also told that he used to smoke 40 packs of cigarettes in a fortnight and for the last 6 months he had stopped smoking before he becomes ill and admitted to hospital (Ivanick et al., 2019). He does not use any illicit drugs and also rarely or just occasionally he used to drink alcohol.

When he told about his family history, it was found that the deficiency of ?₁ – antitrypsin was there in his mother and sister both; his mother also had a disease of chronic obstructive pulmonary (Hirai et al., 2017). His father has a myocardial infarction and died at the age of 63 years. When the patient examined in the context of pneumonia case study was under examination, he was afebrile, sedated and intubated. His blood pressure measure was 89/22 mm Hg, his rate of respiratory was 38 breaths per minute and his rate of pulse measure was 50 beats per minute. In this phase, he was given ventilator support (Orsini et al., 2020). In it the heart sounds and the bowel sound were normal, however, the breath sound heard bilaterally, and some swelling was there in the arms and legs of 2+ edema. The serum protein electrophoresis and the plasma anion gap were found to be normal. Urine appeared cloudy. urine analysis was done, It has 1+ albumin and 2+ urobilinogen (Yoshimi, Satou and Mori, 2018). His report also says that he has 3 to 5 white cells, 5 to 15 red blood cells, renal tubular cells per high power field were very few, squamous cells were few, few reansitional cells, 30 to 90 granular casts per low-power field, 20 to 100 hyaline cast and mucin (Mangioni et al., 2019).

In the chest radiography that was seen in the scenario of pneumonia case study, there is a need for placing the tubes of esophagogastric and endotracheal. Further, a severe increase in bilateral multifocal consolidation with no pleural effusion and pneumothorax occurred. The oxygen inspired with an increasing fraction of 1.00, the Partial Pressure of Arterial Oxygen (PaO₂) increase till 93 mm Hg, and with an oxygen saturation of 95% (Wang et al., 2018). He was given meropenem, methylprednisolone, vasopressin, infusions of fentanyl and propofol. I stop giving imipenem later. The polymorphonuclear leukocytes amount was moderate which was revealed during the gram's staining of the sputum specimen. The test was negative for parainfluenza, respiratory syncytial virus, and antigens to adenovirus (Furumido et al., 2019). For influenza A and influenza B viruses, nucleic acid testing was performed. 

The treatment for the patient requires antifungal chemotherapy containing two drugs. The treatment will also administer corticosteroids. After the completion of the therapy, and exercise-induced hypoxemia and restrictive ventilator impairment persist at one year.

4. What are the findings obtained from the research on pneumonia case study?
In one of the studies considered to prepare this pneumonia case study, it was found that pneumonia is very common in the age group range from 66 to 88 years and is more likely to be community-acquired pneumonia (Sonaglioni et al., 2019). In another of the studies, it was found that around 14,069 Medicare patients whose age was greater than 65 years were hospitalized due to a severe case of community-acquired pneumonia. Another study investigated to develop this pneumonia case study signifies that the elderly age group difference was between 78 ± 8?years (Kwon et al., 2018). This may be due to the hospitalization rate and health care access that have a different population of elderly. Most incidences for the elderly patients having pneumonia are due to loss of elastic recoil of lungs, mechanical clearance of airways, decrease in respiratory muscle strength which causes coughing, declining of mucociliary clearance that is mostly related to age, cumulative effects of comorbid chronic diseases, defects in cell-mediated immunity and humoral (Prendki et al., 2018). 

When studying the cases with sex distribution in order to support the scenario of pneumonia case study, it is observed that more than 70 % of the male is affected than the females as the percentage of the female is more or less 30 % (lès-Nancy and Vandœuvre-lès-Nancy, 2019). This may be due to the reason that male has increased rates in smoking and alcoholism. Additionally, it may also be due to increased cardiac failure or COPD.

5. Conclusion
From the critical analysis on the pneumonia case study, it can be stated that Pneumonia is a serious problem in elderly patients, and it is a very common problem that has been encountered in the medical practice. The elderly patient’s most common symptoms are respiratory symptoms of pneumonia, gastrointestinal symptoms, tachypnea, tachycardia, and crepitation. Many times, Etiological agents would be difficult to identify in the elderly patient for the collection of sputum. Sometimes there are also difficulties in isolating the causative organisms. Thus, in such a case, empirical therapy may be needed. The findings obtained from the pneumonia case study signifies that the climatic conditions and the environmental conditions contribute the most to increase the incidence of pneumonia to occur to the respiratory system with infection and inflammation with the lungs of the alveolar spaces.

References

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