NR 508 Advanced Pharmacology Pneumonia Case Study: NR 508 Pneumonia (Community-Acquired) Sara Martinez: Chamberlain College of Nursing

Pneumonia (Community-Acquired) Sara Martinez Chamberlain College of Nursing NR:508 Advanced Pharmacology April 2018 Grand RoundsPNEUMONIA ▪ Case Study Presentation ▪ Medication Management ▪ Evidence Based Support ▪ Barriers to Practice ▪ Identifying Outcomes ▪ Test Questions 2Case Study Presentation- Present case with a fictional patient who presents to the clinic with Pneumonia. Detailed description of patient, including signs and symptoms of Pneumonia. ▪ 35 year old male presents with fever and cough. Well until 3 days ago when he suffered the onset of nasal stuffiness, mild sore throat, and productive cough small amount of clear sputum. And spasms of coughing that produce purulent secretions. ▪ PMH- smoker of 1 pack per day since he was 15 years old, no current medications, no hospitalizations no drug allergies. ▪ Social history- occasional beer or wine in moderation and occasional headache in which he takes acetaminophen ▪ Meds: acetaminophen as needed for occasional headache 3Case Study Presentation Cont'd ▪ Physical exam: inspiratory “rales” heard at right lung base ▪ Vitals: B/P 168/92, HR 110, RR 23. T 100.9 º F, Pulse Oximetry 93% ( RA) ▪ Chest X-ray reveals bilateral lower lobe infiltrates more pronounced on right side ▪ Sputum culture reveals S.Pneumoniae ▪ CBC ordered Noted: leukocytosis - white blood cell count of 13,500 cells/ µL ▪ Serum electrolytes ordered BUN- normal 4Community-Acquired Pneumonia ▪ ETIOLOGY ▪ The extensive list of potential etiologic agents in CAP includes bacteria, fungi, viruses, and protozoa. Newly identified pathogens include metapneumoviruses, the coronaviruses responsible for severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome, and community-acquired strains of methicillin-resistant Staphylococcus aureus (MRSA). Streptococcus pneumoniae is most common, other organisms also must be considered in light of the patient’s risk factors and severity of illness. Separation of potential agents into either “typical” bacterial pathogens or “atypical” organisms may be helpful. S.Pneumoniae is a gram-positive diplococci usually in the upper respiratory tract (Mandell & Wunderink, 2014) ▪ In general, pneumococcal resistance is acquired (1) by direct DNA incorporation and remodeling resulting from contact with closely related oral commensal bacteria, (2) by the process of natural transformation, or (3) by mutation of certain genes (Mandell & Wunderink, 2014). 5Diagnosing Community-Acquired Pneumonia ▪ Physical Examination- Respiratory signs are varied, including dullness to percussion in areas of the chest with significant consolidation, crackles on auscultation, reduced expansion of the chest in some cases as a result of splinting to reduce pain, bronchial breathing in a minority of cases, pleural rub in occasional cases, and cyanosis in cases with significant hypoxemia. Among infants with severe pneumonia, chest wall in drawing and nasal flaring are common. Non-respiratory findings can include upper abdominal pain if the diaphragmatic pleura is involved as well as mental status changes, particularly confusion in elderly patients (Stern, Cifu, & Altkorn, 2014). ▪Diagnostic testing- 1)Sputum culture- Sputum may be clear or discolored. Discoloration arises from tracheobronchial epithelium cells and WBCs and is not diagnostic of bacterial infection. ( 55-92 % sensitive, 100% specific) (Stern, Cifu, & Altkorn, 2014). 2)Chest x-ray- Usually shows diffuse symmetric bilateral alveolar or interstitial infiltrates (81– 93% of cases) (Stern, Cifu, & Altkorn, 2014). 3) Testing for influenza – most likely negative 4)CBC- for elevation in white blood cell count