Case Study on Pneumonia

Case Study Pneumonia and Pressure Ulcer streak in an old MICU Patient June 6, 2012 Case Study Pneumonia and Sepsis in an Elderly MICU Patient L. M. is a 75-year-old female who suffers from severe dementia and lives in a SNF. She was diagnosed with lung cancer in 2005 and as a result had a secure upper and spirit lobectomy. She too has a history of severe emphysema. L. M. has had several pneumonic infections and has an allergic reaction to Pneumovax. She has a recurrent breathing in jeopardy and received a tracheotomy and a PEG tube in January 2012. On Aril 25, 2012, L.M. was found to be increasingly fatigued, somnolent, and had shortness of breath accompanied with tachycardia as witnessed by the round at the SNF. When she arrived at the emergency department, she was tachycardic with a kernel rate in the 130-140s and tachypnic with a respiration rate in the 30-40s. L. M. , who normally depends on 2 liters of oxygen at home, desaturated to 88% requiring oxygen support increm ent to 4 liters. Her baseline systolic blood blackjack is 100-110 and it was measured in the low 90s in the ED. She also had an increased temperature of 38. degrees Celsius. As a result of L. M. s increase in temperature, heart rate, and respiratory rate accompanied with pneumonia, the emergency department treated her for sepsis. Labs drawn showed an increase in white blood cells and lactic acid, as well as an increase in PC02 and a cliff in PO2. She was aggressively resuscitate with IV bol theatrical roles as essential followed by main tennerance normal saline. She was also administered Vancomycin, Cefepime, Azithromycin, and Metronidazole. In addition, her chest x-ray illustrated a near complete opacification of the right lung field.She was diagnosed with sepsis secondary to pneumonia complicated by a right get lung collapse due to mucus plugging. I assumed manage of L. M. in the MICU ten days after her admission in the ED. She had been intubated and put on a mechanical vent ilator. She was put on coerce sensation support mode at a rate of 10, PEEP of 5, Fi02 of 40%, and her tidal spates averaged around 230. She had iii bronchoscopies, however, there was still evidence of mucous plugs and L. M. was un subject to clear lung secretions. respiratory therapy attempted to decrease the pressure support on the ventilator unless L.M. showed increased signs of respiratory distress. At the point that I took over upkeep for the uncomplaining, my goals were prevent aspiration and further counterpane of infection and improve ventilation system and perfusion. Interventions for my tolerant to prevent aspirations and decrease bump of further infection include suction contaminated secretions, raise the head of the bed, and use of Chlorexidine wash. Protocol for suctioning an intubated patient in the MICU is every 4 hours or more frequently if obligatory depending on the patient. L. M. ad a history of recurrent aspirations and was at risk for increased infect ion because she was on a ventilator. Closure of the glottis prevents aspiration of oropharyngeal secretions. When a patient is intubated with an endotracheal tube, the glottis remains open, leaving only the inflated manacle for protection against aspiration (Bennett, Bertrand, Penoyer, Sole & Talbert, 2011). Therefore, routine suctioning sustains to eliminate the pooling of secretions above the buffet of the endotracheal tube, where aspiration is most likely to occur.In addition, raising the head of the bed to 30-45 degrees decreases aspiration and the risk of ventilator-associated pneumonia. The single most cost-free intervention found to reduce the relative incidence of VAP is lift of the HOB (Stonecypher, 2010). Although my patient was already diagnosed with pneumonia, it was classic to prevent the spread of the infection to the healthy portion of her lungs or have a income tax return of sepsis. Chlorehexidine is an antiseptic that has been proven to inhibit dental plaqu e formation and gingivitis.I swabbed my patients mouth with Chlorhexidine once a shift as a protocol in her plan of care. The use of an antiseptic solution helps to decrease the amount of bacterium in the oral mucosa and thus prevents the village of bacteria in the respiratory tract (Institute for healthcare Improvement, 2012). Another important intervention was to maintain the head of the bed at 30-45 degrees and position L. M. s left lung into a dependent position to improve ventilation and perfusion. L. M. s O2 was decreased to 63 and her CO2 was increased to 50.According to the IHI, it is recommended to elevate the bed to 30- 45 degrees to improve ventilation. Patients that lay in the supine position have lower spontaneous tidal volumes on pressure support ventilation compared to those displace at more of an angle (Institute for Healthcare Improvement, 2012). In regards to positioning, when the least change portion of the lung is placed in a dependent position it receives pr eferential blood flow. This redistribution of blood flow helps match ventilation and perfusion, therefore, improving bollocks up exchange (Lough, Stacy & Urden, 2010).Implementing these interventions combined with respiratory therapy, significantly improved the blood float values for oxygen and carbon dioxide levels. Pressure ulcers are key clinical indicators of the standard and effectiveness of care (Elliott, Fox & McKinley, 2008). L. M. was at high risk for pressure ulcers for multiple factors such as immobility, poor nutrition, age, and health. Therefore, I use the Braden Scale as a character reference indicator in lodge to assess the risk of pressure ulcers and also to initiate prevention.The Braden Scale assesses pressure sore risks by examining certain criteria sensory perception, moisture, activity, mobility, nutrition, and fiction and shear. Each kinsfolk is rated on a scale of 1-4, with the exception of the friction and shear socio-economic class that is rated on a scale of 1-3. There is a possible tot of 23. If a patient has a higher score, they are less subject to development of a pressure ulcer and vice versa. In the category of sensory perception, I rated L. M. at a 2 because she only responded to abominable stimuli but could not communicate discomfort with the exception of restlessness.I scored her at a 2 in the moisture criteria because she was often diaphoretic because of increased heart rate, increased respirations, and her linens had to be changed once a shift. In terms of activity, she was a 1 because she was confined to a bed both at the infirmary and at the SNF she lived in. L. M. was very limited in her mobility and would only make episodic slight changes in her body position therefore, I assessed her to be a 2. I rated her nutrition at a 2 because she weighed 84 pounds and was on tube feeding that seemed inadequate o meet her nutritional needs. In the last category, friction and shear, I gave her a 1 since she required utte rmost take to heartance in moving. She would frequently slide down in her infirmary bed and required frequent reposition. L. M. s cumulative score was a 10, which is considered a high risk for developing a pressure ulcer. Prevention of pressure ulcers is a fundamental aspect of intensive care nursing, and quality procession methods are arguably the most cost-effective and intuitive onrush to addressing this potentially serious problem (Elliott, Fox & McKinley, 2008). One of the interventions I implemented in order to prevent pressure ulcers in my patient was the use of support surfaces. The use of a pressure-redistributing mattress and pillow supports under bony prominences, assist in relieving pressure that the patients body weight has on the skin when lying in bed for a pro-longed amount of time. If the pressure is not alleviated it can lead to impaired circulation, damage to the skin, and in the end tconsequence death (Gill, Reddy & Ronchon, 2006).In order to further promote patient care, it is necessary to educate the patient, family, and/or caregivers. There are several different factors that could help to ensure a better quality of life for L. M. Consistent trach care and good oral hygiene can reduce the risk of bacteria entering the airways and causing recurrent respiratory infections. It is important for L. M. to maintain an elevation of the head of the bed to prevent aspiration and improve ventilation. Furthermore, frequent repositioning and the use of supportive devices is imperative to maintain skin integrity.It will also be crucial to monitor L. M. s vital signs to be able to recognize a recurrence of pneumonia or sepsis. References Bennett, M. , Bertrand, M. , Penoyer, D. A. , Sole, M. L. , & Talbert, S. (2011). Oropharyngeal secretion volume in intubated patients The importance of oral suctioning. American Hournal of Critical Care, 20(6), 141-145. Elliott, R. , Fox, V. , & McKinley, S. (2008). Quality improvement program to reduce the preval ence of pressure ulcers in an intesive care unit. American Journal of Critical Care, 17(4), 328-334.Retrieved from http//ajcc. aacnjournals. org/content/17/4/328. full Gill, S. S. , Reddy, M. , & Ronchon, P. A. (2006). Preventing pressure ulcers A systematic review. The Journal of the American Medical Association, 296(8), Retrieved from http//jama. jamanetwork. com/article. aspx? volume=296&issue=8&page=974 Institute for Healthcare Improvement. (2012). Ihi ventilator bundle perfunctory oral care with chlorhexidine. Institute for Healthcare Improvement, Retrieved from http//www. ihi. org/ intimacy/Pages/Changes/DailyOralCarewithChlorhexidine. spx Institute for Healthcare Improvement. (2012). Ihi ventilator bundle Elevation of the head of the bed. Institute for Healthcare Improvement, Retrieved from http//www. ihi. org/knowledge/Pages/Changes/ElevationoftheHeadoftheBed. aspx Lough, M. E. , Stacy, K. M. , & Urden, L. D. (2010). Critical care nursing. St. Louis, MO Mosby Elsevier. Ston ecypher, K. (2010). Ventilator-associated pneumonia The importance of oral care in intubated adults. Crtitical Care Nursing Quarterly, 33(4), 339-347.