Aspiration Pneumonia

1. Diagnosis: Aspiration Pneumonia Chelsea, Elisha, Jessica, Lisa, Morgan

2. Case Information • 27 year old, male • Admitted with uncontrollable fever • Transferred from long term care facility • Hx. of gunshot wound to left chest resulting in cardiac arrest • Developed hypoxic encephalopathy • Has tracheostomy and gastronomy tubes • Hx. of MRSA • Devoted family Chelsea, Elisha, Jessica, Lisa, Morgan

3. Assessment • Thin, cachetic man • Moderate respiratory distress • Unresponsive to voice, touch, painful stimuli • VS: T=40°C, P=120, R=30, SpO₂=90% • Crackles and scattered wheezes in upper left lobe • Serum albumin 2.8g/dl • WBC count 1.8x10⁹/L • Sputum specimen thick, green and foul smelling; cultures pending • ABG: pH 7.29, PaO₂80mmHg, PaCO₂40mmHg, Bicarbonate 16 mEq/L • Stool culture positive Clostridiumdifficile • Chest x-ray: infiltrate in left upper lobe; no pleural effusions noted Chelsea, Elisha, Jessica, Lisa, Morgan

4. What is it? Aspiration Pneumonia Chelsea, Elisha, Jessica, Lisa, Morgan

5. Aspiration Pneumonia Pathophysiology • Aspiration pneumonia is caused by the abnormal entry of secretions or substances into lower airway. These substances them provide an environment for bacteria to grow. There are four stages of aspiration pneumonia pathophysiology and they are as follows: • Congestion: when bacteria reach alveoli the organisms multiply and fluid flows out of the alveoli • Red hepatization: massive dilation of capillaries and alveoli are filled with bacteria, organisms, neutrophils, red blood cells and fibrin • Grey hepatization: blood flow decreases and leukocytes and fibrin accumulate in the affected part of the lung • Resolution: complete resolution and healing occur if there are no complications Chelsea, Elisha, Jessica, Lisa, Morgan

6. What is it? Hypoxic Encephalopathy Chelsea, Elisha, Jessica, Lisa, Morgan

7. Hypoxic Ecephalopathy Pathophysiology • Hypoxic encephalopathy is a condition in which the entire brain does not receive enough oxygen, but isn’t completely deprived • Within as little as five minutes of oxygen deprivation, brain cells can begin dying. The disease can also cause long-term damage including: • Mental retardation • Delayed development • Seizures • Cerebral palsy • Severe oxygen deprivation can result in: • Coma • Lack of brain stem reflexes (breathing and responding to light) • Only blood pressure and heart function reflexes are functioning Chelsea, Elisha, Jessica, Lisa, Morgan

8. What is it? Clostridium difficile Chelsea, Elisha, Jessica, Lisa, Morgan

9. Clostridium Difficile Pathophysiology • Most serious cause of antibiotic associated diarrhea • Most common symptoms are watery diarrhea, fever, and abdominal pain or tenderness • When the C diff bacteria, that normally reside in the body become overgrown, it can cause severe infection of the colon, colitis, and eradication of the normal gut flora by antibiotics • The overgrowth is harmful because the bacterium releases toxins that can cause bloating, constipation, diarrhea, and abdominal pain • Can be flu- like symptoms • Discontinuation of the causative antibiotic is often curative • If it becomes more serious, treatment by oral admin of metronidazole or vancomycin • Typical antibiotics that cause C diff are: ampicillin, amoxicillin, and cephalosporins. • Some less common causative antibiotics are: penicillin, erythromycin, trimethoprim, and quinolones • Some that rarely cause C diff are: tetracycline, metronidazole (Flagyl), and gentamicin Chelsea, Elisha, Jessica, Lisa, Morgan

10. Tracheostomy Tube • A tube inserted into the trachea to allow for a patent airway. • It is inserted below the larynx and as a result the vocal chords no longer function Chelsea, Elisha, Jessica, Lisa, Morgan

11. Gastrostomy Tube • A tube inserted directly into the stomach • Nutrition is administered totally through this tube. The patient takes nothing by mouth • A P.E.G tube is a Percutaneous Endoscopic Gastronomy tube. This refers to how the tube is inserted Chelsea, Elisha, Jessica, Lisa, Morgan

12. Lab Values What does it all mean? Chelsea, Elisha, Jessica, Lisa, Morgan

13. Lab Values • Serum Albumin • Pt. Value: 2.8 g/dL • Normal Range: 3.4-5.4 g/dL • Protein in highest concentrations in plasma – main transport protein • Values affected by synthesis, distribution, and degradation processes • Decreased levels maybe due to inadequate production, excessive loss • To determine if a patient has liver, kidney disease or if not enough protein is being absorbed by the body Indicates nutritional status, hydration, chronic disease Chelsea, Elisha, Jessica, Lisa, Morgan

14. Lab Values • White Blood Cells • Pt. Value: 18000 µL (18 x 109/L) • Normal Range: 3.8-10.8 x 109/L • Neutrophils, eosinophils, basophils, monocytes, lymphocytes produced in bone marrow – body’s defense system • Life span of cell is 13-20 days, old cells destroyed by lymph system and excreted in feces • Increased count: leukocytosis • Decreased count: leucopenia Chelsea, Elisha, Jessica, Lisa, Morgan

15. Lab Values • Arterial Blood Gas • Evaluates respiratory function • Determines: acid-base balance, if patient is in a respiratory or metabolic imbalance • Pt. pH: 7.29 • Normal Range: 7.35-7.45 • Changes in ratios of free H+ to bicarbonate result in compensatory response from: lungs (respiratory) or kidneys (metabolic) Chelsea, Elisha, Jessica, Lisa, Morgan

16. Lab Values • Arterial Blood Gas • Pt. PaO2: 80 mmHg • Normal Range: 80-95 mmHg • Used to calculate hemoglobin saturation and availability of O2 for critical organs • With PaCO2, used to measure O2 gradient of alveolar-arterial gradient indicating effectiveness of gas exchange Chelsea, Elisha, Jessica, Lisa, Morgan

17. Lab Values • Arterial Blood Gas • Pt. PaCO2: 40 mmHg • Normal Range: 35-45mmHg • Important indicator of ventilation: • Conditions that interfere with normal breathing causes CO2 to be retained in blood • Conditions that increase breathing rate will cause CO2 to be removed from alveoli more rapidly than it is produced resulting in alkaline pH • Level controlled primarily by lungs therefore is respiratory component of acid base balance Chelsea, Elisha, Jessica, Lisa, Morgan

18. Chelsea, Elisha, Jessica, Lisa, Morgan Arterial Blood Gas Metabolic Together Respiratory Opposite

19. Nursing Diagnosis Chelsea, Elisha, Jessica, Lisa, Morgan

20. Impaired gas exchange r/t to collection of mucus in airways and inflammation of airways and alveoli • Objective Data • PaO2 80 mmHg • Pa CO2 40mmHg • Respiratory Rate of 30 • Heart Rate of 120 Chelsea, Elisha, Jessica, Lisa, Morgan

21. Impaired gas exchange r/t to collection of mucus in airways and inflammation of airways and alveoli • Interventions • Assess respirations • Monitor changes in vital signs • Assess skin for cyanosis • Monitor ABGs and oxygen saturation • Maintain oxygen administration device as ordered • Anticipate need for intubation if condition worsens • Expected Outcomes • Patient maintains optimal gas exchange as evidenced by eupnea and normal ABGs Chelsea, Elisha, Jessica, Lisa, Morgan

22. Ineffective airway clearance r/t to increased sputum due to pneumonia • Objective Data • Respiratory Rate 30 • O2 Saturation 90% • Chest auscultation revealed crackles and scattered wheezes in the left upper lobe • Chest x-ray; infiltrate in left upper lobe • Interventions • Assess respiratory movements and use of accessory muscles • Assess sputum color, amount, and odor and report changes • Auscultate lung sounds • Monitor pulse oximetry • Monitor chest x-ray reports Chelsea, Elisha, Jessica, Lisa, Morgan

23. Ineffective airway clearance r/t to increased sputum due to pneumonia • Interventions • Sit the patient up in bed • Maintain adequate hydration • Use humidity • Assist with oral pharynx suctioning if necessary • Provide oral care • Consult respiratory therapist for chest physiotherapy and nebulizer treatments • Expected Outcomes • Patient airway is free of secretions as evidenced by eupnea and clear lung sounds Chelsea, Elisha, Jessica, Lisa, Morgan

24. Infection r/t to aspiration from tracheotomy • Objective Data • Temperature 40˚C • O2 Saturation 90% • Crackles and scattered wheezes heard throughout lung fields • WBC 18000/μl • Sputum specimen: thick, green colored, foul smelling • Chest x-ray: infiltrate in left upper lobe • Interventions • Assess vital signs, monitor temp • Obtain sputum for culture and sensitivity • Monitor lung sounds Chelsea, Elisha, Jessica, Lisa, Morgan

25. Infection r/t to aspiration from tracheotomy Interventions • Monitor WBC • Assess hydration • Monitor pulse oximetry • Monitor chest x-ray reports • Administer antimicrobial agents • Use appropriate therapy for elevated temperatures; antipyretics, cold therapy • Isolate patients as necessary after review of culture and sensitivity • Expected Outcomes • Patient experiences improvement in infection as evidenced by normo-thermia, normal WBC count & negative sputum culture report on repeat culture Chelsea, Elisha, Jessica, Lisa, Morgan

26. Imbalanced Nutrition: less than body requirements r/t gastronomy tube, inability to swallow and diarrhea r/t C.Difficile • Objective Data • Cachetic appearance • G-Tube in situ • Positive Clostridium Difficile stool culture • Nursing Interventions • Ensure feeding schedule is maintained • Ensure continued support from Registered Dietician • Check placement and patency of tube • Measure amount of feeding exactly Chelsea, Elisha, Jessica, Lisa, Morgan

27. Imbalanced Nutrition: less than body requirements r/t gastronomy tube, inability to swallow and diarrhea r/t C.Difficile • Interventions • Monitor lab values (electrolyte levels, hematocrit, hemoglobin, blood glucose, and total protien) • Treat C.Difficile appropriately • Expected Outcomes • Pt. will attain an increased nutrition status as evidenced by body weight will be within 10% of ideal body weight for his age and height Chelsea, Elisha, Jessica, Lisa, Morgan

28. Infection r/t antibiotics • Objective Data • History of MRSA in sputum • Admitted because of uncontrollable fever • Stool culture positive for Clostridium difficile • WBC count 18,000/ul (18 x 109/L) (normal 3.8-10.8 x 109/L) • Temperature 1040F (40oC) • Interventions • Note risk factors causing the infection (prolonged antibiotic use, weakened immune system, other infections • Stress proper hand hygiene by all caregivers and family members • Use isolation precautions (gown and glove for c.diff but if MRSA is in sputum then everyone needs to mask as well) Chelsea, Elisha, Jessica, Lisa, Morgan

29. Infection r/t antibiotics • Interventions • Provide information such as pamphlets or handouts to family on the pathophysiology of c diff and ways to reduce spread of infection • Maintain sterile technique for all invasive procedures • Encourage position changes to prevent any further complications • Administer antibiotics as indicated • Expected Outcomes • Family of patient will verbalize the understanding of the use of disease precautions and the importance of them during the first day of care. • Family will identify interventions to prevent the spread of infection during the first couple days on the unit • Family will demonstrate techniques, lifestyle changes to promote safe environment upon discharge Chelsea, Elisha, Jessica, Lisa, Morgan

30. Risk for deficient fluid volume r/t C.Diff • Objective Data • Stool culture positive for C.Diff • Interventions • Monitor urine output, intake, and record on data sheet, and observe color and odor of urine • Weigh daily (same time and scale) • Evaluate lab tests such as: electrolytes, blood urea, creatinine, total protein) • Evaluate nutritional status • Assess vital signs (temp, pulse, and resps, BP) • Watch for changes in usual function Chelsea, Elisha, Jessica, Lisa, Morgan

31. Risk for deficient fluid volume r/t C.Diff • Interventions • Administer fluids and electrolytes as indicated • Educate patient and family on factors related to occurrence of deficit • Modify care plan if patient is not getting the nutrients he needs • Expected Outcomes • Patient will maintain stable vital signs, urine output, skin turgor, and moist mucous membranes throughout admission • Will verbalize understanding of causative factors and purpose of interventions when LOC is appropriate • Patient will demonstrate behaviors to monitor and correct this deficit Chelsea, Elisha, Jessica, Lisa, Morgan

32. Risk for impaired skin integrity r/t C.diff • Objective Data • Stool culture positive for c.diff • Interventions • Assess circulation and sensation • Watch for redness or non blanching skin around bony prominences • Teach patient the importance of good peri-care • Note any odors coming from wounds • Inspect skin on a daily basis • Keep perineum is clean and dry, and teach client how to manage incontinence Chelsea, Elisha, Jessica, Lisa, Morgan

33. Risk for impaired skin integrity r/t C.diff • Interventions • Maintain cleanliness of bedding so pt is not soiled for a prolonged amount of time • Reposition client q2h so skin breakdown will not occur • Prevent any shearing or tearing of skin if transferring or from movement • Assess client psychological status for risks of feeling helpless • Expected Outcomes • Patient will participate in preventative measures and treatment program while in care • Patient will maintain optimal nutrition and physical well being while in care • Patient will verbalize feelings of increased self- esteem and ability to manage situation upon discharge Chelsea, Elisha, Jessica, Lisa, Morgan

34. Discussion Questions • What types of infectious disease precautions should be taken related to Sam’s hospitalization? • To prevent to spread of any disease in a facility, staff should practice scrupulous hand hygiene • Patients with diarrheal illnesses should be isolated. • Gowns & gloves should be worn by all personnel attending to the infected patients. • With the possibility of MRSA, masks should also be worn • Linens should be disinfected. Surfaces potentially infected be clostridium spores should be treated with bleach • Personal care items should not be shared or reused Chelsea, Elisha, Jessica, Lisa, Morgan

35. Discussion Questions • What clinical manifestations of aspiration pneumonia did Sam exhibit? Explain their significance. • Temperature of 40°C • Crackles and scattered wheezes in left, upper lobe • X-ray showed infiltrate in left, upper lobe • Respiratory rate of 30 • SpO₂ of 90% • Green, thick, fowl smelling sputum • Elevated WBC Chelsea, Elisha, Jessica, Lisa, Morgan

36. Discussion Questions • What antibiotic medication is likely to be prescribed? • Patients with mild to moderate c diff. typically improve with oral metronidazole or vancomycin. • More severely infected patients may need infusions of vancomycin directly into the GI tract. • Metronidazole is also highly effective in treating lower respiratory tract infections such as pneumonia Chelsea, Elisha, Jessica, Lisa, Morgan

37. Discussion Questions • What other clinical issues need to be addressed regarding his care? • Skincare – risk for breakdown • Hydration – increased requirement r/t diarrhea • Oral care deficit r/t tubing, decreases fluid intake • Impaired coping - Family coping • Changed may be required in long term facility Chelsea, Elisha, Jessica, Lisa, Morgan

38. Discussion Questions • What family interventions would you initiate? • Education re: good hand hygiene, infection control precautions (isolation). This will limit the spread is C Diff. • The family should avoid visiting while they are sick • Family support systems – Initiate contact with support group for children with brain injury • Respite care • Stress management techniques Chelsea, Elisha, Jessica, Lisa, Morgan

39. Chelsea, Elisha, Jessica, Lisa, Morgan