CASE STUDY

Presented to: Dr. Amal Behar

Floor: ICU
Done by: Salwa Kassem Karaman
ID: 202306112
 OUTLINE:
SITUATION
Introducing the case ( The current Situation of the patient) + medical diagnosis
Current Medication
BACKGROUND Nursing Care Plan
History of Present Illness
Past Medical History RECOMMENDATIONS
Plan of care.
ASSESSMENT
Physical Assessment (Objective Data ) REVIEW OF DISEASE PROCESS
Lab Results Definition
Pathophysiology
Diagnostic Procedures Critical Analysis of results
Risk Factors
Etiology
Signs and Symptoms

Nursing and Medical Management

REFERENCES
 INTRODUCING THE CASE:

• PT W.K , a 82 years old female patient, non smoker, was admitted on the 15/7/ 2023 to the
emergency department then transferred to ICU, presented with productive cough, diagnosed
with right lower lobe pneumonia. Patient KTH: HTN, ALZH, asthma. Past surgical history
includes: hysterectomy and cholecystectomy. Family medical history includes: heart disease,
hypertension, cancer. Patient is on facemask 5LO2, peripheral iv line 250cc NSS , foley
inserted, pt is on Lasix push 20mg
 HISTORY OF PRESENT ILLNESS:

• This is a case of 82 yo female pt with : htn, alzheheimer, asthma, presented for cough productive with sputum,
dyspnea, desaturation(84%), fever reaching 39to the ER. Family reported that they started yesterday tavanic
750mg po, exomuc and Panadol with no improvement. Patient denied any other major symptoms. In Er, Cxr
done and showed right lower lobe pneumonia, crp 2.95, wbc 13.6 spo2 95% on nc 4L. Vitals are stable.
 PHYSICAL EXAMINATION:

 Bilateral diffuse crackles with expiratory wheezes

 Regular S1 S2
 Soft non tender abdomen
 No neurological focal deficit
 Conscious but not well cooperative and oriented
 No lower limb edema
HOME MEDICATIONS:

Medication Dose Route Frequency Date and time

name last taken
quotiepius 25mg Po QD 9pm
Remeron 30mg Po QD 5pm
Exomuc 200mg Po QD 3 schets Tid
Alprox 0.25 Po QD 9pm
Current medications:
Medication Dose Route Frequency time
name
Meropenem 1g Ivd Q8h 1ma-9pm-
5pm
Lovenox 40mg s/c QD 5pm
Quetapre 12.5mg PNG QD 5pm
Pulmicort 1mg By neb Q12 9am/pm
Tavanic 750mg Ivd QD 5pm
Bisoprolol 2.5 mg PNG QD 5pm
Duphalac 30cc PNG QD 5pm
Exomuc 200mg PNG TID 9am/pm-
1pm
Amlor 5mg PNG QD 8am
luganor 40mg Ivd QD 9am
MEROPENEM: (FUNC. CLASS.: ANTIINFECTIVE—
MISCELLANEOUS)
• ACTION: Bactericidal; interferes with cell-wall replication of susceptible organisms; osmotically unstable cell wall
swells, bursts from osmotic pressure
• USES: Serious infections caused by gram-positive bacteria: Streptococcus pneumoniae, group A β-hemolytic streptococci,
enterococcus; gram-negative: Klebsiella, Proteus, Escherichia coli, Pseudomonas aeruginosa; appendicitis, peritonitis
caused by viridans group streptococci; Bacteroides fragilis, Bacteroides thetaiotaomicron, bacterial meningitis (≥3 mo)
• CONTRAINDICATIONS: Hypersensitivity to this product, carbapenems, cephalosporins, penicillins
• SIDE EFFECTS
• CNS: Seizures, dizziness, weakness, headache
• CV: Hypotension, palpitations, tachycardia
• GI: Diarrhea, nausea, vomiting, pseudomembranous colitis, hepatitis, glossitis
• INTEG: Rash, urticaria, pruritus, pain at inj site, phlebitis, erythema at inj site
• RESP: Dyspnea, hyperventilation
• SYST: Anaphylaxis, Stevens-Johnson syndrome, angioedema
NURSING CONSIDERATIONS
Assess:
• Sensitivity to carbapenem antibiotics, penicillins
• Renal disease: lower dose may be required; monitor serum creatinine/BUN
before, during therapy • Pseudomembranous colitis: bowel pattern daily; if
severe diarrhea, fever, abdominal pain, fatigue occurs, product should be
discontinued • Infection: temp, sputum, characteristics of wound before, during,
and after treatment Allergic reactions, anaphylaxis: rash, laryngeal edema,
wheezing, urticaria, pruritus; may occur immediately or several days after
therapy begins, identify if there has been hypersensitivity to penicillins,
cephalosporins, beta-lactams, cross-sensitivity may occur • Seizures: may occur
in those with brain lesions, seizure disorder, bacterial meningitis, or renal
disease; stop product, notify prescriber if seizures occur • Overgrowth of
infection: perineal itching, fever, malaise, redness, pain, swelling, drainage, rash,
diarrhea, change in cough, sputum
Teach patient/family:
• Pseudomembranous colitis: to report severe diarrhea
• To report sore throat, bruising, bleeding, joint pain; may indicate blood
dyscrasias (rare) • To report overgrowth of infection: black, furry tongue; vaginal
itching; foul-smelling stools • To avoid breastfeeding; product is excreted in
breast milk
 CONCOR: ( BISOPROLOL) FUNC. CLASS.:
ANTIHYPERTENSIVE

• ACTION: Preferentially and competitively blocks stimulation of β1-adrenergic receptors within

cardiac muscle (decreases rate of SA node discharge, increases recovery time), slows conduction of
AV node, decreases heart rate, which decreases O2 consumption in myocardium; decreases renin-
angiotensin-aldosterone system; inhibits β2-receptors in bronchial and vascular smooth muscle at high
dose
• USES: Mild to moderate hypertension
• CONTRAINDICATIONS: Hypersensitivity to β-blockers, cardiogenic shock, heart block (2nd, 3rd
degree), sinus bradycardia, CHF, cardiac failure
• SIDE EFFECTS: Ventricular dysrhythmias, profound hypotension, bradycardia, CHF, 2nd-or 3rd-
degree heart block
NURSING CONSIDERATIONS
Assess:
• Hypertension: B/P during beginning treatment, periodically thereafter; pulse
q4hr: note rate, rhythm, quality; apical/radial pulse before administration; notify
prescriber of any significant changes (pulse <50 bpm) • Baselines of renal,
hepatic studies before therapy begins
• CHF: I&O, weight daily; increased weight, jugular venous distention, dyspnea,
crackles, edema in feet, legs daily • Skin turgor, dryness of mucous membranes
for hydration status, especially for geriatric patients

Teach patient/family:
Not to discontinue product abruptly; may cause precipitate angina, rebound hypertension; evaluate
noncompliance
• Not to use OTC products that contain α-adrenergic stimulants (e.g., nasal
decongestants, OTC cold preparations) unless directed by prescriber • To report
bradycardia, dizziness, confusion, depression, fever, cold extremities
• To take pulse at home; advise when to notify prescriber
• To avoid alcohol, smoking, sodium intake
• To comply with weight control, dietary adjustments, modified exercise
program
 LUGANOR: PANTOPRAZOLE
FUNC. CLASS.: PROTON PUMP INHIBITOR
• ACTION: Suppresses gastric secretion by inhibiting hydrogen/potassium ATPase enzyme system in gastric parietal cell; characterized as
gastric acid pump inhibitor because it blocks the final step of acid production
• USES: Gastroesophageal reflux disease (GERD), severe erosive esophagitis; maintenance of long-term pathologic hypersecretory
conditions, including Zollinger-Ellison syndrome
• CONTRAINDICATIONS: Hypersensitivity to this product or benzimidazole
• SIDE EFFECTS
• GI: Diarrhea, abdominal pain, flatulence, pancreatitis, weight changes
• INTEG: Rash
• META: Hyperglycemia, weight gain/loss, hyponatremia, hypomagnesemia
• MS: Rhabdomyolysis, myalgia
• RESP: Pneumonia
• SYST: Stevens-Johnson syndrome, toxic epidermal necrolysis, anaphylaxis,
• angioedema
NURSING CONSIDERATIONS
Assess:
• GI system: bowel sounds q8hr; abdomen for pain, swelling; anorexia
• Hepatic studies: AST, ALT, alk phos during treatment
• For vit B12 deficiency in patients receiving long-term therapy
Serious skin reactions: toxic epidermal necrolysis, Stevens-Johnson
syndrome, exfoliative dermatitis: fever, sore throat, fatigue, thin ulcers; lesions
in the mouth, lips • Electrolyte imbalances: hyponatremia; hypomagnesemia in
patients using product 3 mo to 1 year; if hypomagnesemia occurs, use of
magnesium supplements may be sufficient; if severe, discontinuation of product
may be required Rhabdomyolysis, myalgia: muscle pain, increased CPK;
weakness, swelling of affected muscles

Teach patient/family:
• To report severe diarrhea; black, tarry stools; abdominal pain; product may
have to be discontinued • That hyperglycemia may occur in diabetic patients
• To avoid alcohol, salicylates, NSAIDs; may cause GI irritation
• To notify prescriber if pregnant or planning to become pregnant; not to
breastfeed • To continue taking even if feeling better
 ENOXAPARIN (LOVENOX): FUNC. CLASS.:
ANTICOAGULANT, ANTITHROMBOTIC
• ACTION: Binds to antithrombin III inactivating factors Xa/IIa, thereby resulting in a higher ratio of anti-
factor Xa to IIa
• USES: Prevention of DVT (inpatient or outpatient), PE (inpatient) in hip and knee replacement, abdominal
surgery at risk for thrombosis; unstable angina/non–Qwave MI
• CONTRAINDICATIONS: Hypersensitivity to this product, benzyl alcohol, heparin, pork; active major
bleeding, hemophilia, leukemia with bleeding, peptic ulcer disease, thrombocytopenic purpura, heparin-
induced thrombocytopenia
• SIDE EFFECTS
• CNS: Fever, confusion
• HEMA: Hemorrhage, hypochromic anemia, thrombocytopenia, bleeding
• INTEG: Ecchymosis, inj site hematoma
• META: Hyperkalemia in renal failure
NURSING CONSIDERATIONS
Assess:
• Blood studies (Hct/Hgb, CBC, coagulation studies, platelets, occult blood in
stools), anti-factor Xa (should be checked 4 hr after inj); thrombocytopenia may
occur
• Renal studies: BUN/creatinine baseline and periodically
• Bleeding: gums, petechiae, ecchymosis, black tarry stools, hematuria; notify
prescriber

Teach patient/family:
• To use soft-bristle toothbrush to avoid bleeding gums; to use electric razor
• To report any signs of bleeding: gums, under skin, urine, stools
• To avoid OTC products containing aspirin unless approved by prescriber
LAB VALUES: (BLOOD CHEMISTRY)
Patient lab Patient lab Normal ranges
values( upon values( last lab
admission) values)
BUN: 13 BUN: 14 5-25 mg/dl
Creatinine: 0.72 Creatinine: 0.81 0.2-1.2 mg/ dl
Protein total: - Protein total: 6.68 6.0-8.4 g/dl
Albumin: - Albumin: 3.16 3.5-5.0 g/dl
Globulin:- Globulin: 3.52 2.5-3.4 g/dl
Sodium: 143 Sodium: 143 135-145mmol/L
Potassium: 3.76 Potassium: 3.65 3.5-5mmol/ L
Chloride: 107 Chloride: 101 93-110 mmol/L
Bicarbonate: 25 Bicarbonate: 32 22-29mEq/L
Magnesium: - Magnesium: 1.6 1.6-2.6mg/dl
Calcium: - Calcium: 9.2 8.5-10.5mg/dl
Phosphorous: - Phosphorous: 2.8 2.8-4.5mg/dl
Crp: 4.14 Crp: 3.51 <1.0 mg/L
 Hematology:
Patient lab values( upon Patient lab values( last Normal ranges
admission) lab values)

Hb: 10.4 Hb: 12.1 12-16g/dl

Ht: 32.1 Ht: 36.2 37-47%
WBC: 10.7/ 10^3/ ul WBC: 11.6/10^3/ul 4000-11000 / mm^3
Neut (Seg): 58.5 Neut (Seg) : 69.9 55-70%
Lym: 24.1 Lym: 20.4 20-40%
Mon: 8.5 Mon: 5.6 2-8%
Eos: 8.7 Eos: 3.7 1-4%
Bas: 0.2 Bas: 0.4 0.5-1.0%
Platelets: 309/ 10/ul Platelets: 350/ 10/ul 150000-400000/ mm^3
Mcv: 86 Mcv: 85 80-95 mm^3
CRITICAL ANALYSIS OF LAB VALUES:

 Serum albumin levels have prognostic value for complications in viral, bacterial, and fungal
infection, and for infectious complications of non- effective chronic conditions. High globulin
levels may be a sign of: Infection.
 A high level of bicarbonate in your blood can be from metabolic alkalosis, a condition that
causes a pH increase in tissue.
 High level of CRP may indicate that there is a serious health condition that causes
inflammation
 Leukocytosis, or high white blood cell count, can indicate a range of conditions, including
infections and inflammation
 DIAGNOSTIC EVALUATIONS:

• Chest xray ( done in the ER) showed right lower lobe pneumonia
• Sputum culture
• Urine culture showed: E.coli
NURSING CARE PLAN:

• Decreased cardiac output r/t altered myocardial infarction as evidence by: ECG changes and
BP changes
• Expected outcomes: patient will demonstrate adequate cardiac outputand decreased episodes
of dyspnea
• Interventions:
• 1- auscultate apical pulses and assess heart rate
• 2- note heart sounds and assess the rhythm and document dysrhtmias
• 3- monitor BP and urine output
Ineffective breathing pattern:
r/t: pulmonary congestion secondary to congestive heart failure
As evidence by: weakness, tachypnea
Expected outcomes: patients respiratory pattern will be effective without causing fatigue
Interventions :
1- position patient in semi fowlers position for breathing
2- assist patient to use relaxation techniques to reduce muscle tension and decrease work oh
breathing

Impaired gas exchange:

r/t: Alveolar edema secondary to increased ventricular pressure
As evidence by: Crackles upon auscultation, Difficulty of breathing, Shortness of breath
Expected outcome: Patient will be able to demonstrate improvement in gas exchange as
evidenced by normal breath sounds, and skin color, presence of eupnea, heart rate 100 bpm or
less, and Sp02 level of 95% above.
Nursing Interventions:
1. Position the patient in a High Fowler’s position with the head of the bed elevated up to 90°.
Promote maximal inspiration, enhance expectoration of secretions to improve ventilation.

2-Promote adequate rest periods

Rest will prevent fatigue and decrease oxygen demands for metabolic demands

3. Keep the environment allergen-free

To reduce irritant effects on airways

4. Suction secretions PRN

To clear the airway when secretions are blocking the airway.

5. Administer oxygen therapy as ordered.

For patients with ADHF, high-flow oxygen is given via a non-rebreathing mask, positive airway pressure devices, or endotracheal
intubation and mechanical intubation. If it improves, oxygen is titrated to maintain pulse oximetry readings greater than 92%.

6. Administer diuretics as ordered.

Diuretics promote normovolemia by decreasing fluid accumulation and blood volume. Fluid overload reduces lung perfusion
leading to hypoxemia.
Impaired Skin Integrity:

r/t: Prolonged bedrest

As evidence by: pressure ulcer: heel stage 1

Expected outcomes: Maintain skin integrity.

Nursing Interventions:

1. Provide gentle massage around reddened or blanched areas.

Improves blood flow, minimizing tissue hypoxia. Note: Direct massage of the compromised area may cause tissue injury.

2. Encourage frequent position changes, assist with active and passive range of motion (ROM) exercises.
Reduces pressure on tissues, improves circulation, and reduces time in any area is deprived of full blood flow.

3. Provide frequent skincare: minimize contact with moisture and excretions.

Excessive dryness or moisture damages skin and hastens breakdown.

4. Avoid intramuscular route for medication.

Interstitial edema and impaired circulation impede drug absorption and predispose to tissue breakdown and development of
infection.

5. Provide alternating pressure, egg-crate mattress, sheepskin elbow, and heel protectors.
Reduces pressure on the skin, may improve circulation.
 PLAN OF CARE:

• Assess cough effectiveness and productivity

• Observe the sputum color, viscosity, and odor. Report changes.
• Assess the patient’s hydration status.
• Suction as indicated: frequent coughing, adventitious breath sounds, desaturation related to airway
secretions.
PNEUMONIA
DEFINITION:

• Pneumonia is an inflammation of the lung parenchyma caused by various

microorganisms, including bacteria, mycobacteria, fungi, and viruses. Pneumonitis is a
more general term that describes an inflammatory process in the lung tissue that may
predispose or place the patient at risk for microbial invasion. Pneumonia and influenza
are the most common causes of death from infectious diseases in the United States.
Pneumonia and influenza accounted for 50,636 deaths in the U. S. in 2012 and 1.1
million discharges from hospitals (Centers for Disease Control and Prevention [CDC],
2015a; CDC, 2015b). Together these diseases were the eighth leading cause of death in
the United States in 2012 (CDC, 2015a).
Classification
Pneumonia can be classified into four types: community-acquired pneumonia (CAP), health care–associated
pneumonia (HCAP), hospital acquired pneumonia (HAP), and VAP (American Thoracic Society & Infectious
Diseases Society of America, 2005; File, 2016). HCAP was added as a category in 2005 to identify patients at
increased risk for Multi drug resistant (MDR) pathogens versus community-acquired pathogens (File, 2016). Chart
23-3 describes the different classifications and definitions of pneumonias. Other subcategories of HCAPs are those
in the immunocompromised host and aspiration pneumonia.
Classifications and Definitions of Pneumonias:

• Community-acquired pneumonia (CAP): Pneumonia occurring in the community or ≤48 hours after hospital
admission or
institutionalization of patients who do not meet the criteria for health care–associated pneumonia (HCAP)

• Health care–associated pneumonia (HCAP): Pneumonia occurring in a non hospitalized patient with extensive
health care contact with one or more of the following:
 Hospitalization for ≥2 days in an acute care facility within 90 days of infection
 Residence in a nursing home or long-term care facility
 Antibiotic therapy, chemotherapy, or wound care within 30 days of current infection
 Hemodialysis treatment at a hospital or clinic
 Home infusion therapy or home wound care
 Family member with infection due to multidrug-resistant bacteria
• Hospital-acquired pneumonia (HAP): Pneumonia occurring ≥48 hours after hospital admission that did not appear
to be incubating at the time of admission
• Ventilator-associated pneumonia (VAP): A type of HAP that develops ≥48 hours after endotracheal tube intubation
ETIOLOGY:

 Causative agents:
o Bacteria
o Mycobacteria
o Fungi
o Viruses
 PATHOPHYSIOLOGY:

Normally, the upper airway prevents potentially infectious particles from reaching the sterile lower respiratory tract.
Pneumonia arises from normal flora present in patients whose resistance has been altered or from aspiration of flora
present in the oropharynx; patients often have an acute or chronic underlying disease that impairs host defenses.
Pneumonia may also result from blood borne organisms that enter the pulmonary circulation and are trapped in the
pulmonary capillary bed. Pneumonia affects both ventilation and diffusion. An inflammatory reaction can occur in
the alveoli, producing an exudate that interferes with the diffusion of oxygen and carbon dioxide. White blood cells,
mostly neutrophils, also migrate into the alveoli and fill the normally air-filled spaces. Areas of the lung are not
adequately ventilated because of secretions and mucosal edema that cause partial occlusion of the bronchi or alveoli,
with a resultant decrease in alveolar oxygen tension. Bronchospasm may also occur in patients with reactive airway
disease.
Because of hypoventilation, a ventilation–perfusion (V./Q.) mismatch occurs in the affected area of the lung.
Venous blood entering the pulmonary circulation passes through the under ventilated area and travels to the left
side of the heart poorly oxygenated. The mixing of oxygenated and unoxygenated or poorly oxygenated blood
eventually results in arterial hypoxemia.
If a substantial portion of one or more lobes is involved, the disease is
referred to as lobar pneumonia. The term bronchopneumonia is used to
describe pneumonia that is distributed in a patchy fashion, having
originated in one or more localized areas within the bronchi and extending
to the adjacent surrounding lung parenchyma. Bronchopneumonia is more
common than lobar pneumonia

Figure 23-2 • Distribution of lung

involvement in bronchial and lobar
pneumonia. In bronchopneumonia (left),
patchy areas of consolidation occur. In lobar
pneumonia (right), an entire lobe is
consolidated
Risk factors:
CLINICAL MANIFESTATIONS:
o Predominant S&S : After few days:
o Headache Mucoid or mucopurulent sputum

o Low grade Fever

o Pleuritic pain Sever pneumonia:
o Myalgia Flushed cheeks
o Rash central cyanosis
o pharyngitis
o Poor appetite
 MEDICAL MANAGEMENT:

 Viral pneumonia:
o Supportive treatment
o Antibiotics if 2ry bacterial pneumonia, bronchitis or sinusitis

 Hydration
 Antipyretics
 Antitussive
 Warm, moist inhalation
 Anti-histamins
 Nasal decongestants

 RBR
 O2 therapy:
• ABGs
• Pulse oximetry
 ETT
 Mechanical ventilation
 NURSING MANAGEMENT:

 Improving airway patency:

o Hydration (2 to 3l / day)
o Humidification
o Effective coughing
o Lung expansion maneuvers: deep breathing, incentive spirometry
o Chest physiotherapy
o Cough and sputum characteristics
o O2 therapy (pulse oximetry, ABGs)
 Promoting rest and conserving energy:
o Rest
o Comfortable position (Semi Fowler`s position)
o Position changes

 Promoting fluid intake

 Maintain nutrition
 Monitoring and managing the complications
REFERENCES:

• Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14th Edition