Aspiration Pneumonia

ASPIRATION PNEUMONIADiagnosis:

Chelsea, Elisha, Jessica, Lisa, Morgan


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


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 Clostridium difficile Chest x-ray: infiltrate in left upper lobe; no pleural effusions noted


Aspiration PneumoniaWhat is it?


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


Hypoxic Encephalopathy

What is it?


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


Clostridium difficileWhat is it?


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


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


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


What does it all mean?

Lab Values


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


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


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)


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


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


Arterial Blood Gas

Acid-Base Disturban

ce

pH pCO2 pO2 HCO3-

Respiratory Acidosis

Uncompensated Decreased Increased Normal NormalCompensated Normal Increased Increased IncreasedRespiratory

AlkalosisUncompensated Increased Decreased Normal NormalCompensated Normal Decreased Decreased Decreased

Metabolic Acidosis

Uncompensated Decreased Normal Decreased DecreasedCompensated Normal Decreased Decreased Decreased

Metabolic Alkalosis

Uncompensated Increased Normal Increased IncreasedCompensated Normal Increased Increased Increased

Metabolic Together Respiratory Opposite


NURSING DIAGNOSIS


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


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


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


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


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


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


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


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


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)


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


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


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


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


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


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



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



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



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



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

Aspiration Pneumonia

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