Grand Rounds Project

[Audio] Hello everyone, my name is Timelisa Smith and I will be presenting my grand rounds project on Community Acquired Pneumonia..

[Audio] Today's agenda consists of an introduction, chief complaint, client's medical history, social history, vital signs/ safety, general physical exam, diagnostic findings, nursing diagnosis, current medications, therapies, referral specialists, education, case-wrap up and references..

[Audio] During the recent clinical rotation at CHM Hospital, I was assigned a client., D.B., who was diagnosed with community acquired pneumonia. I selected her case to explore in the Grand Rounds Project because pneumonia is a common condition that I am likely to encounter while working in the hospital. As a nurse, I need to understand the condition to conduct an assessment, create a care plan, and implement key nursing interventions for patients..

[Audio] DB is a 45-year-old female with no known drug allergies. She presented to the ER 2 days ago with a productive cough (rust colored sputum), dyspnea, pleuritic chest pain, fever of 102.6 degrees, and oxygen desaturation of 91%. It is generally recommended that "patients who have peripheral oxygen saturations< 92 on room air (and a significant change from baseline) be hospitalized" (Ramirez, 2024 p. 11). Based upon the chest x-ray, sputum culture, and vital signs D.B. was admitted to the hospital. At the time of admission her symptoms lasted 3-4 days..

[Audio] D.B.'s does not have a surgical history. The only time that she has ever been admitted to the hospital was during her 3 natural childbirths. She takes one Garden of Life Multivitamin Daily. Her mother had lithotripsy in 2022 because of kidney stones. Her father is a type 2 diabetic. D.B normally takes her annual vaccinations for COVID 19, FLU, and Pneumococcal, but she became sick with pneumonia prior to getting them. These vaccines are important to her because she works as a pre-k teacher and during cold and flu season, the children get sick and at times spread illness. Because she is not inoculated, she feels she could have contracted her illness while working. Young children are still learning to sneeze in their sleeve, wash hands, and other techniques to keep the spread of germs down. This increases her risk of catching respiratory conditions..

[Audio] D.B. is a 45-year-old white female. She is a Preschool Teacher who received a BA in Early Childhood Education at UNCG. Working with young children may have exposed her to the community acquired pneumonia. Young children may forget to wash their hands or practice safe sneezing techniques. D.B. did not receive her annual pneumococcal or flu vaccine at the start of cold and flu season as she typically does which made her vulnerable to contracting pneumonia. D.B does not smoke but her husband of 20 years smoke cigarettes. Harmful chemicals in secondhand smoke can damage lung tissue and impair lung function making it more difficult for the lungs to oxygenate the blood, leading to worsened symptoms like shortness of breath and fatigue. Additionally, secondhand smoke can irritate the airways, leading to increased mucus production which is not conducive to good health and oxygenation in a pneumonia patient. D.B will need education to facilitate healing at home. D.B. is not military affiliated. No recent travel outside of the US within the past year. She drinks a glass of wine once a month and does not use drugs. DB works out 3-5 days a week at the gym. She also eats a healthy diet of steamed greens and lean proteins. These healthy habits should make it easier for her to heal. D.B. is married. She has never had STDs or reproductive illnesses. D.B. and her husband have 3 children who are grown. D.B. lives with her husband. There is no physical, mental, and financial abuse. D.B. does not have any suicidal ideation. She is from the state of North Carolina. D.B. is close to her family. She is a Christian..

[Audio] Viewing D.B.'s admission vitals, it is noted that the Pneumonia caused her lungs to become inflamed and infected. This triggered her body's immune response, which led to her fever of 102.6 degrees. After a few days of the steroid, inflammation in the lungs decreases. With the introduction of the antibiotic, the infection in the body is healing and D.B.'s temperature drops from 102.6 degrees to 99 degrees. The pneumonia inflamed her lungs, making it harder for her body to get enough oxygen. To compensate for this, her heart had to work harder to pump blood leading to an elevated heart rate of 105 beats per minute. As the inflammation decreases, her heart rate decreases to a normal rate of 82 beats per minute. Inflamed and infected lungs caused D.B.'s lungs to compensate by breathing more rapidly to get enough oxygen. This rapid breathing is often referred to as tachypnea or an increased respiratory rate. For D.B., her respiratory rate was 24 breaths per minute at admission. Nursing interventions such as the delivery of oxygen to the body, the administration of pain medication, antibiotics, and steroids improve D.B.'s breathing. The next set of vital signs reveal normal respirations of 18 and oxygen saturation goes from 91% to 97% indicating the combination of treatments are working. Her body is getting enough oxygen, and tissues are being perfused properly. D.B.'s blood pressure reading 127/94. This is likely attributable to the pleuritic chest pain she reported. Pain elevates the blood pressure. Over time, we see this number trend downward when her pain and pneumonia are treated. The new blood pressure is 119/72. D.B.'s initial pain assessment was a 5 out of 10. She experienced pleuritic chest pain. Pleuritic chest pain is a sharp, stabbing pain in the chest that worsens with deep breaths, coughing, or sneezing. It's caused by inflammation of the pleura, the thin lining that covers the lungs and the inside of the chest wall. Steroids and antibiotics will eventually treat the cause of this condition. To immediately make sure that D.B.'s pain goal of 1 is met. The doctor prescribed her Oxycodone 5mg every 6 hours. D.B. met her pain goal of 1/10. However, taking Oxycodone made her a fall risk. The facility made sure she had a bed alarm. Her bed was always left in the lowest position, and she was told to "call before she falls." Her community acquired pneumonia initial symptoms of fatigue, shortness of breath, weakness already made her fall risk, but the narcotic increases the likelihood of her falling..

[Audio] Listed are some common nursing diagnoses for community acquired pneumonia. They include ineffective breathing pattern, impaired gas exchange, acute pain, risk for infection, activity intolerance, imbalanced nutrition less than body requirements..

[Audio] This is the general physical exam for D.B. There are vital signs in slide 7 that shows her improving over time. No known drug allergies. Not on isolation precautions Neurological: Alert and Oriented to Name, Date, Place, Time, Reason. Pupils are equal round and reactive to light and accommodation. No headaches, dizziness, weakness noted, no tingling, tremors. Some loss of balance and decreased coordination. No previous falls or difficulty swallowing. Pain is a 5 out of 10. It is pleuritic chest pain. No facial drooping, normal upper and lower motor strength with sensation in extremities. Respiratory: Tachypnea (Respiratory Rate "24") upon admission with adventitious breath sounds. Crackles and wheezing apparent in the right and left lung lobes. Oxygen saturation 91%. Productive cough with rust colored sputum. Pleuritic chest pain 5/10. Gastrointestinal: No abdominal pain, cramping, pain tenderness or masses. Recent nausea and no vomiting. No constipation. Loss of appetite (anorexia). No difficulty swallowing. Auscultated bowel sounds over all quadrants (sounds are present) Last bowel movement this morning. It was normal. Genitourinary: No pain or burning when voiding. No urgency or frequency when voiding. Normal urine. No incontinence issues. No bladder distention. Integumentary: No skin concerns such as itching rashes or an unusual lump or mole. Not cyanotic, no jaundice, erythema, bruising, normal turgor. IV site is present with no redness warmth, tenderness at the insertion site. No skin breakdown on pressure pints behind ears, occipital area, elbow, sacrum and heels. Upon palpation, the skin temperature is warm (102.6 degrees oral temperature.) Head and Face: No problem with teeth or gums that impacts ability to eat. D.B does not use glasses hearing aids or dentures. There is no difficulty seeing or blurred vision; no trouble hearing or experience ring in the ears. Eyes and ears and oral cavity are lesion free. Cardiovascular: The client has pleuritic chest pain. Some shortness of breath, no edema, palpitations, calf pain, pain in their feet or lower legs. Face, lips, and extremities are normal in color. No JVD. No signs of DVT. Elevated heart rate and rhythm (105 beats per minute). All pulses normal strength. Capillary refill normal. BP is slightly elevated 127/94. This is likely caused by pleuritic pain. Monitoring her vital signs and administering medication as prescribed is essential to help B.D. stabilize..

[Audio] D.B. chest x-ray shows multi-lobar infiltrates. A "chest radiograph, is the accumulation of WBC's and fluid within the alveoli that appears as pulmonary opacities" (Ramirez, 2024 p. 9). D.B. lungs were filled with infection and inflammation. D.B.'s physician used data from the x-ray and the information gathered from the sputum culture (identifies type of bacteria) to select an antibiotic and implement interventions to treat D.B.'s community acquired pneumonia. Ancef (Cefazolin) 2 gm/20 ml Q8H IV push was the antibiotic prescribed. D.B.'s WBC was 19.6 initially, which is elevated. An elevated WBC count in pneumonia is a sign that D.B.'s body was actively fighting the infection. This number improves as treatment continues. There was an Elevated C-reactive protein (CRP) indicating inflammation in the lungs, but this was treated with antibiotics and steroids. I am surprised that there was no information for arterial blood gases in the patient's chart. Monitoring oxygenation through ABG's can inform treatment options, but I was at the hospital for limited shifts and additional data may not have been returned prior to me leaving..

[Audio] D.B. was prescribed Deltasone because this corticosteroid is an anti-inflammatory. By reducing inflammation, Deltasone can improve lung function and tissue perfusion which helps oxygen saturation levels in the body. Easier breathing will decrease symptoms of pneumonia such as tachypnea. Evidence of this medication's effectiveness is seen with D.B.'s vital signs stabilizing. D.B. does not take any other the counter drugs or herbal remedies. Prior to treatment, her only supplement was a multivitamin..

[Audio] Ancef or cefazolin is a first-generation cephalosporin antibiotic. The causative agent for D.B.'s community acquired pneumonia was identified. The infection in her lungs was sensitive to Ancef so her physician prescribed it. By eliminating infection, Ancef decreases inflammation making it easier for her to breathe. The antibiotic is a broad-spectrum antibiotic so it can kill multiple causative agents. Over time, mucus production diminished and D.B.'s lung function is improving..

[Audio] Oxycodone is an opioid analgesic that binds to opiate receptors in the CNS to manage pain. One of D.B.'s initial complaints was pleuritic chest pain. Her pain level was a 5 out of 10. D.B.'s pain goal was a 1 out of 10. By taking this medication 5 mg every 6 hours, D.B.'s pain level decreased to 1 out of 10. It is likely that her blood pressure decreased as pain is better managed. This medication when combined with Valerian root can increase the risk of respiratory depression and sedation. Patient teaching is necessary when a patient takes this drug in combination with herbal remedies..

[Audio] Lovenox is an anticoagulant that is standard treatment for all patients in the hospital for prevention of Deep Vein Thrombosis, Pulmonary Embolism, and/or Venous Thromboembolism. Because D.B. recuperates in bed. She receives this injection daily. D.B. should avoid garlic, gingko bilbo, and ginger because the supplements increases the risk of bleeding and so does this medication..

[Audio] Miralax is an osmotic laxative that works by drawing water into the colon, which softens the stool and stimulates bowel movements. Miralax is a necessary medication for D.B. Because of her pleuritic pain, she needs to take an opioid analgesic, Oxycodone. Opioid analgesics decrease motility in the GI tract. Miralax helps with the severe constipation that normally accompany opioid use. The patient does not have any recreational or medical alternatives used for treatment..

[Audio] D.B.'s physical therapist can provide her with some range of motion exercises she can use while she is in her hospital bed or when she gets home that can help strengthen muscles. Additionally, the PT can help the patient understand positions to get in that help with postural drainage. Postural drainage is a technique that uses gravity to help drain mucus from the lungs. This can be beneficial for people with pneumonia because it helps to: Loosen mucus: By positioning the body in different ways, gravity helps to loosen mucus that has built up in the lungs. Improve drainage: The loosened mucus can then be coughed up more easily, reducing congestion in the lungs. Reduce inflammation: Improved drainage can help reduce inflammation in the lungs, which can alleviate symptoms like cough and shortness of breath. Promote healing: By removing mucus and reducing inflammation, postural drainage can help the lungs heal more quickly. The dietician gives insight nutrient-rich meals to help maintain a healthy immune system enabling it to fight and heal from pneumonia..

[Audio] The pulmonologist can help manage symptoms including oxygenation, monitor recovery, prescribe medications, and tailor patient treatment for community acquired pneumonia. The respiratory therapist can assess lung function, offer inhaler or nebulizer therapy. Respiratory therapists can conduct chest physiotherapy on a patient. Using various therapies ensures that D.B. experiences better health outcomes..

[Audio] Educating the patient is priority. This decreases visits to the emergency room and hospital stays. Also, education means the patient is more likely to follow the treatment plan. Mortality rates increase with less patient education. D.B. needs education on smoking cessation for her spouse. The patient's husband smokes. Secondhand smoke can trigger inflammation in the lungs, making her more susceptible to infection. It can prolong D.B.'s healing time so being in the vicinity of the smoking needs to stop. The patient needs education on receiving the flu and pneumococcal vaccinations as recommended by the CDC guidelines because they decrease the risk of respiratory complications. Handwashing is the standard process for reducing germ transmission and keeping the patient safe. When D.B. is in class, she can wear a respirator mask when children are coughing and sneezing. D.B. needs to take her medication as prescribed. Antibiotics need to be taken as prescribed. Missing doses or stopping antibiotics prematurely can create super bugs. Oxycodone should be taken as prescribed because there is a risk for respiratory depression. Corticosteroids that are used long-term need tapering. These medications can raise glucose levels so monitor consumption of carbohydrates. Eat a balanced meal recommended by the dietician and contact your provider if you feel symptoms are returning, notice undesirable changes, and to follow up with care. The patient will verbalize understanding of learned topics..

[Audio] Interventions that were included in D.B.'s patients to provide supplemental oxygen per hospital policy. Encourage the client to drink fluid. This thins out the mucus in patients with pneumonia. Using the incentive spirometer in pneumonia. Regular use of an incentive spirometer can help strengthen the muscles used for breathing, improving lung function. Controlled coughing helps to dislodge and expel mucus from the lungs, reducing congestion and inflammation. The semi-fowlers position is for better oxygenation, promotes drainage, and prevents aspiration for patients with pneumonia. Take a steroid reduces inflammation promoting adequate oxygen saturation. Oxycodone is for pain relief of pleuritic chest pain. Ancef heals infection. Lovenox prevents blood clots. Miralax counteracts the constipation associated with Oxycodone. Monitoring D.B.'s vital signs every four hours allows me to be proactive as a nurse..

[Audio] What actually happened with D.B. is Oxygen saturation improved from 91% to 97%. Respirations decreased from 24 to 18 breaths per minute. Her body temperature cooled from 102.6 degrees to 99 degrees. D.B.'s blood pressure trended downward from 127/94 to 119/72. D.B. pain was goal met. D.B.'s inflammation and infection improved. This was evidenced by D.B. breathing better and producing less mucus. An opportunity for improvement in the plan based on outcomes is The World Health Organization recommends that "people of all ages can reduce their risk of pneumonia by getting vaccinated, washing their hands, maintaining a healthy style, and eating a health diet" (Pneumonia, 2024 p. 2). The hospital staff can create a local campaign urging the community to take action to reduce pneumonia and other respiratory conditions through vaccination, handwashing, diet, and education..

References. Pneumonia. (2024). World Health Organization. https://www.who.int/health-topics/pneumonia/#tab=tab_3 Ramirez, J. (2024, November 12). Overview of community-acquired pneumonia in adults. https://www.uptodate.com/contents/overview-of-community-acquired-pneumonia-in-adults/print Musher, D. M., & Shoar, S. (2020). Etiology of community-acquired pneumonia in adults: a systematic review. Pneumonia (Nathan Qld.), 12, 11. https://doi.org/10.1186/s41479-020-00074-3.