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Nursing Management of a Patient with Nosocomial Pneumonia Melanie Rose F. Avila Dorothy Gail C. Cabatuan Our Lady of Fatima University, Quezon City

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Nursing Management of Patient with Nosocomial Pneumonia

M.R a 76 year old male, with no medical history of hypertension and no previous hospitalization. He was diagnosed with nosocomial pneumonia. The patient has no evidence of infection at the time of the admission. The onset of the pneumonia symptoms is more than 48 hours after the admission. The patient had a fever with the highest range of 39.2 degrees Celsius and the lowest fever range is 37.7 degrees Celsius since June 16 2011 until July 10 2011. He had peripheral leukocytosis, and a persistent infiltrate on the chest xray. Nosocomial Pneumonia also called as Hospital-Acquired Pneumonia accounts for approximately 15% of hospital acquired infection and is the leading cause of death in patients with such infection (File 2007). It tends to be more serious, because the patient's defense mechanisms against infection are often impaired during a hospitalization. In addition, the types of germs present in a hospital are often more dangerous than those encountered in the community. The patient is present under mechanical ventilator via endotracheal tube. According to American Thoracic Society (ATS 2007) guidelines, nosocomial pneumonia is the second-most-common nosocomial infection and is usually bacterial in origin. The disease adds significantly to the cost of hospital care and to the length of hospital stays.According to Brunner(2008), Hospital-acquired pneumonia tends to be more serious than other lung infections, because patients in the hospital are often sicker and unable to fight off germs. Because the types of germs present in a hospital are often more dangerous than those encountered in the community.

Nursing Management 3 Pathophysiology Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacterium, fungi and viruses. Normally the upper airway prevents potentially infectious particles from reaching the sterile lower respiratory tract. Pneumonia arises from normal flora present in the 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 exudates that interfere 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. Ares of lung are not equally ventilated because of secretions and mucosal edema that cause partial occlusion of the bronchi or alveoli, with a resultant decrease in alveolar oxygen tension. Pneumonia occurs in patient with certain underlying disorder such as heart failure, diabetes, alcoholism, chronic obstructive pulmonary disease, and acquired immunodeficiency syndrome. Certain diseases also have pathogens. Pneumonia varies in its signs and symptoms including Cough that produces greenish, mucus like pus like sputum, Shortness of breath, Fever, Headache, Chest pain that Increases by coughing or by breathing deeply, body malaise and Vomiting and an uneasy feeling of nausea. (MS Book, Brunner&Suddarth 2008) According to American Thoracic Society (ATS 2007) The development of nosocomial pneumonia represents an imbalance between normal host defenses and the ability of microorganisms to colonize and then invade the lower respiratory tract. Because aerobic gram-negative bacilli are the major pathogens associated with nosocomial pneumonia, the pathophysiology of the disease relates to the destructive effect of these organisms on invaded lung tissue. Aerobic gram-negative pathogens may be divided into 2 categories. The first category includes organisms that cause necrotizing pneumonia with rapid cavitations, micro abscess formation, blood-vessel invasion, and hemorrhage. The

Nursing Management 4 second category consists of all other nonnecrotizing gram-negative organisms responsible for nosocomial pneumonia. History M.R a 76 year old male has no medical history of hypertension and no previous hospitalization. The patient is a passive smoker. Three months prior to admission patient experienced no bowel movement for two weeks. This was not associated by abdominal pain, abdominal distinction, no fever until ten weeks prior to admission, the patients condition persisted poor associated with abdominal pain. Patient sought consult and had ultrasound of the whole abdomen. A gallbladder stone was detected. Patient was advised surgery but optioned to transfer to an institution. Hence, he was diagnosed with sepsis secondary to nosocomial pneumonia, resolving; acute radiation syndrome secondary to acute tubula necrosis resolving acute calculous cholecytitis, choledocholithiasis status post endoscopic cholangio pyelography with common bile duct stone in May 2011.

Nursing Physical Assessment M.R was lying on bed unconscious and hooked on mechanical ventilator witj regulation of TV=350, F1O2= 45, PUR=24, PF=70. The patients temperature was 38.9 degrees celcius, cardiac rate was 119 bpm, respiratory rate was 20 cpm,blood pressure was 80/60 mmHg, oxygen saturated in room iar was 95%, and the patients level of care was level 4. The patient had an IV heplock on his left arm during our clinical hours and also inserted D5 NSS 1 liter + 1 amp neurobion + 40 meqs Kcl x15gtts/min at around 1600H. the patients skin was cool to touch and with blister on his arms and legs, he had bedsore below his buttocks 5mm in diameter and 1mm in depth. The patients bowel sounds were hypoactive and observed had no bowel movement as of 09 July 2011. The total urine output x8 hours noted 1600H at the first day of our clinical duty. His diet is 1300kcal in 24 hours in 6 divided feeding through kangaroo pump.

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Related Treatments The patient has an IV heplock on his left vein, with 1 liter of D5W isotonic solution. According to Brunner, once it is administered, the glucose of is rapidly metabolized. It is used mainly supply water and to correct on increased serum osmolality. About 1 liter of D5W provides fewer than 200kcal. The patient is taking medication of Cilastatin 500mg thru IV every 8 hours.It is for killing the e.coli bacteria present. The patient is taking levofloxacin 750mg once daily. It is also treatment of wide infections including lower respiratory tract infection. The physician also prescribed paracetamol 300mg every 4 hours IV for fever and human albumin 25%, IV once daily for increase oncotic deficiency and followed by 2 ampules of furosemide to increase diuresis. Since the patients underwent surgery, the physician ordered Tramadol 40mg IV, 8 hours. It is for severe acute or chronic pain during surgery procedures. Since the patient is unconscious, all the medication routes are thru intravenous.And the mode of feeding to our patient is osterize feeding of 1300kcal x 24 divided in 6 equal feedings. Blood glucose monitoring every before osterize feedings and monitored every 4 hours to determine hypo or hyperglycemia is present. Our patient is also using mechanical ventilator which was regulated at FI02=45, TV=350, BUR=24, PF=70.According to Kozier(2008), the parenteral administrations of medication are absorbed more quickly than oral medications. The primary purpose of giving IV medications is to initiate a rapid systemic response to medication. The drug is immediately available to the body. It is easier to control the actual amount of drug delivered to the body by using the IV method and it is also easier to maintain drug levels in the blood for therapeutic response.

Nursing Management 6 Nursing Care Plan M.Rs nursing diagnosis is ineffective airway clearance related to infection secondary to nosocomial pneumonia (NANDA). The patient has elevated temperature, with the highest range of 39.2 degrees Celsius and the lowest fever range is 37.7 degrees Celsius since June 16 2011 until July 10 2011, the blood pressure of 80/60mmHg , respiratory rate of 20 beats per minute, and cardiac rate of 114 beats per minute. The patient is pale, had difficulty in breathing, restlessness, diminished breath sound, uses accessory muscle in breathing. Chest x-ray confirmed pneumonia. The main goal is to maintain airway patency and move sputum out of the lungs to facilitate normal breathing patterns and eradicate infection causing his problem. The short term goal is to maintain the airway patency and the excretions will rapidly expectorate and there will be signs of reduction in congestion. Nursing interventions for the patient is to maintain working capacity of mechanical ventilator and breath sounds, noting rate and sounds indicative of respiratory distress or accumulation of secretions. Auscultate breath sounds and assess airway movement to ascertain status and note progress. Monitor vital sign, blood pressure ad pulse changes. Observe for signs of respiratory distress. Monitor chest x-ray, abg, pulse oximetry readings. Nursing intervention for the patient is to monitor respirations and breath sounds, noting rate and sounds indicative of respiratory distress or accumulation of secretions. Auscultate breath sounds and assess airway movement to ascertain status and note progress. Monitor vital sign, blood pressure ad pulse changes. Observe for signs of respiratory distress. Monitor chest x-ray, abg, pulse oximetry readings. To evaluate the status of oxygenation, ventilation and acid base balance. Administer prescribed medications for infections and bronchodilators to help aiding effective airway clearance. To evaluate the status of oxygenation, ventilation and acid base balance. Administer prescribed medications for infections. Provided supplemental humidification via use of nebulizer. Because nebulization helps in liquefying secretions for better and faster expectorating secretions.

Nursing Management 7 Recommendation

Infection control measures can help to prevent the spread of any type of infection, including pneumonia. Infection control is most commonly practiced in healthcare settings, but is useful in the community as well. Simple practices such as frequent hand washing with soap and water or alcohol-based hand rubs can be effective.

Because pneumonia is spread by contact with infected respiratory secretions, people with pneumonia should limit face-to-face contact with uninfected family and friends. The mouth and nose should be covered while coughing or sneezing, and tissues should be disposed of immediately. Sneezing/coughing into the sleeve of one's clothing (at the inner elbow) is another means of containing sprays of saliva and secretions and has the advantage of not contaminating the hands.

Nursing Management 8 Reference Smeltzer, Suzzane C. , Brunner and Suddarths Textbook of medical-Surgical Nursing. P. 554564 Mims, 127th edition 2011 Kozier and Erbs, Fundamentals of Nursing p. 839 American Thoracic Society. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005 Feb 15;171(4):388-416. Niederman MS (2004). Pneumonia,nosocomial pneumonia. In JD Crapo et al., eds., Baum's Textbook of Pulmonary Diseases, 7th ed., vol. 1, pp. 424-454. Philadelphia: Lippincott Williams and Wilkins.