Name: Grand Rounds Project
Uploaded: 2024-12-02
Duration: 23 min 51 s
Description: Hello everyone, my name is Timelisa Smith and I will be presenting my grand rounds project on Community Acquired Pneumonia..

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

Scene 1

Community Acquired Pneumonia Timelisa Smith Nursing 527-7A Med Surg II Herzing University Dr. J. Blake Smith, DNP, APRN, CNE November 30, 2024

A diagram of a lungs

Description automatically generated

[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.. 

Scene 2

Grand Rounds Project Cover Agenda Introduction Chief Complaint Client’s Medical History Social History Vital Signs/Safety Nursing Diagnoses General Physical Exam Diagnostic Findings/Lab Findings Current Medications Deltasone

Current Medications Ancef Current Medications Oxycodone Current Medications Lovenox Current Medications Miralax Therapies Referral to Specialists Educational Needs Case Wrap Up 1 Case Wrap Up 2   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.. 

Scene 3

In the article, Etiology of Community-Acquired Pneumonia in Adults: A Systematic Review, pneumonia is described “…as new pulmonary infiltrate on chest X-ray or computerized tomography (CT) together with ≥ 2 of the following findings: New or Worsening Cough Sputum Production Shortness of Breath Pleuritic Chest Pain Fever or Hypothermia Oxygen Desaturation Confusion Leukocytosis or Leukopenia” (Musher & Shoar, 2020 p. 3).

TYPICAL COMMUNITY ACQUIRED PNEUMONIA
ACUTE it«EcT10N OF THE PAQE&CHYAA
ACQUIRED OUTSIDE OF THE HOSPITAL OR
THAN 48 HOURS AFTER HOSPITAL ADMISSION
MOST COMMON
CAUSE Of TYPICAL CAP r;
STREPTOCOCCUS PNEUMONIAE
WWW.MEXO
vEvE2. ca-æ. SPUTUM PQODUCTION. QIGOQ$.
PLEURITIC CHEST PAIN. DYSPNEA. TACHYCARDIA
BREATH
SOUNDS AND CRACKLES
AUSCULTATIa-4
SPECIAL DUE TO
LOBAR CONSOLIDATION
• WOUSPEQED PETOQILOOUY
• vQEM1tU5
(XREASED)
NINETY-NINE!
NINETY-NINE!
INFILTRATE ON
CHEST RADIOGRAPH
0 201'

[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.. 

Scene 4

Patient: D.B. Age: 45 Gender: Female Allergies: No Known Drug Allergies Duration of Symptoms: 3 to 4 days Current Complaint: Productive cough (rust colored sputum), (dyspnea) shortness of breath, oxygen desaturation, pleuritic chest pain and fever.

A clipboard with a document on it

Description automatically generated

[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.. 

Scene 5

A cartoon of a doctor and patient

Description automatically generated

D.B. No surgical history D.B. Medical History includes 3 Natural Childbirths (She was 22, 24, 26 years old during each birth) Daily Multivitamin Mother: Kidney Stone Removal (Lithotripsy) in 2022 Father: Type 2 Diabetic for 10 years. D.B. Takes annual pneumococcal vaccine but became sick prior to getting the shot.

[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.. 

Scene 6

A blue and white background with black text

Description automatically generated

D.B. is 45-year-old white female Teaches Early Childhood Education No Military Affiliation No smoking; husband smokes No history of STDs, same partner for 20 years Drinks 1 glass of wine monthly. Works out 3-5 Days; Eats Healthy Married with 3 Grown Children 1 Grandchild that Visits (aged 1) 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.. 

Scene 7

Admitting Vitals October 5, 2024 5 pm Pain Assessment: 5/10 with a Goal of 1/10.  Temperature: 102.6 (Oral) Pulse: 105 Respiration: 24 Blood Pressure: 127/94 Oxygen Saturation:   91%

Latest Vital Signs October 8, 2024 7 am Pain Assessment: 1/10 with a Goal of 1/10. Goal met. Temperature: 99 (Oral) Pulse:  82 Respiration: 18 Blood Pressure:  119/72 Oxygen Saturation: 97%

A diagram of a vital signs

Description automatically generated

A group of smiley faces with different colors

Description automatically generated with medium confidence

[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.. 

Scene 8

Nursing Diagnoses 
Community Acquired Pneumonia

1. Ineffective Breathing Pattern Related to: Inflammation of the lung parenchyma, increased respiratory effort, and fatigue. As evidenced by: Tachypnea, dyspnea, use of accessory muscles, and decreased oxygen saturation.
 2. Impaired Gas Exchange Related to: Alveolar consolidation, inflammation, and decreased alveolar-capillary membrane surface area. As evidenced by: Decreased oxygen saturation, dyspnea, 
 3. Acute Pain Related to: Inflammation of the pleura and chest wall. As evidenced by: Pleuritic chest pain, guarding behavior, and restlessness.

A clipboard with a pen and graph

Description automatically generated

4. Risk for Infection Related to: Weakened immune system and invasive procedures (e.g., intubation). As evidenced by: Fever, leukocytosis, and purulent sputum.
 5. Activity Intolerance Related to: Fatigue, weakness, and shortness of breath. As evidenced by: Decreased activity level, fatigue, and shortness of breath with minimal exertion.
 6. Imbalanced Nutrition: Less Than Body Requirements Related to: Anorexia, fatigue, and difficulty breathing. As evidenced by: Weight loss, decreased appetite, and poor oral intake.

[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.. 

Scene 9

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 or 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 is 91%. Productive cough with rust colored sputum. Pleuritic chest pain 5/10. Gastrointestinal: No abdominal pain related to the GI system, no cramping, pain tenderness or masses. Recent nausea and no vomiting. No constipation. Loss of appetite (anorexia) related to pneumonia. 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 D.B. 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.. 

Scene 10

Chest X-Ray (Multi-Lobar Infiltrates seen on X-ray) Chest radiograph, accumulation of WBCs and fluid within the alveoli appears as pulmonary opacities” (Ramirez, 2024 p. 9) Sputum Gram Stain and Culture Arterial Blood Gases

[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.. 

Scene 11

Deltasone, or Predisone  Classification: Corticosteroids are a class of hormones produced naturally by the adrenal glands Purpose/Mechanism of Action: Anti-inflammatory Dosage: Quantity: Two 5 mg tablets (10 mg daily) Contraindications: Systemic fungal infections: Prednisone should not be used in patients with active or recent systemic fungal infections, as it can worsen these conditions. Hypersensitivity: Patients with known hypersensitivity to prednisone or any of its ingredients should avoid using this medication. Adverse Reactions and Side Effects: Prednisone can cause a wide range of adverse reactions and side effects, which can vary in severity and frequency depending on the individual and the duration of treatment. Some of the common side effects include: Fluid retention: Prednisone can cause fluid retention, leading to swelling in the ankles, feet, and legs. Increased blood sugar: Prednisone can increase blood sugar levels, which can worsen diabetes or cause new-onset diabetes. Muscle weakness: Prednisone can weaken muscles, making it more difficult to perform daily activities. Thinning of the skin: Prednisone can thin the skin, making it more prone to bruising and tearing. Osteoporosis: Long-term use of prednisone can increase the risk of osteoporosis, a condition that weakens bones and increases the risk of fractures. Cushing's syndrome: Long-term use of high doses of prednisone can lead to Cushing's syndrome, a condition characterized by a round face, weight gain, and other symptoms. Increased risk of infection: Prednisone can suppress the immune system, making it more difficult for the body to fight off infections. Mental health changes: Prednisone can cause mood swings, anxiety, and depression. Gastrointestinal problems: Prednisone can cause stomach ulcers, heartburn, and other gastrointestinal problems.

A close-up of a prescription

Description automatically generated

[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.. 

Scene 12

Ancef, or cefazolin,  Classification: A first-generation cephalosporin antibiotic.  Purpose/Mechanism of Action: Cephalosporins are a class of antibiotics that work by interfering with the bacteria's cell wall synthesis Dosage: 2 grams/20 ml Q8H IV Push
 Contraindications Known allergy to cephalosporin antibiotics: Patients with a known allergy to cephalosporins should avoid Ancef due to the risk of severe allergic reactions. Severe hypersensitivity to penicillins: While less common, cross-sensitivity between penicillins and cephalosporins can occur. Adverse Reactions/Side Effects While Ancef is generally well-tolerated, it can cause some side effects, including: Gastrointestinal disturbances: Diarrhea, nausea, and vomiting Hypersensitivity reactions: Rash, itching, hives, and in severe cases, anaphylaxis Blood disorders: Eosinophilia, thrombocytopenia, and hemolytic anemia Renal impairment: In rare cases, kidney damage can occur, especially in patients with pre-existing kidney problems Neurological effects: Seizures, particularly in patients with underlying neurological conditions or renal impairment

A close-up of a label

Description automatically generated

[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.. 

Scene 13

Oxycodone Classification: Opioid Analgesic Purpose/Mechanism of Action: Binds to Opiate Receptors in the CNS; Reduce Pain Dosage: 5 mg Q6H Contraindications: Severe respiratory depression: Oxycodone should not be used in patients with severe respiratory depression, as it can worsen this condition and lead to respiratory failure. Acute or severe asthma: Patients with acute or severe asthma should avoid oxycodone, as it can worsen breathing difficulties. Paralytic ileus: Oxycodone should not be used in patients with paralytic ileus, a condition that causes a blockage in the intestines. Known or suspected bowel obstruction: Oxycodone can worsen bowel obstruction, and should not be used in patients with this condition. Hypersensitivity: Patients with known hypersensitivity to oxycodone or any of its ingredients should avoid using this medication. Adverse Reactions and Side Effects: Oxycodone can cause a wide range of adverse reactions and side effects, which can vary in severity and frequency depending on the individual and the dose being used. Some of the common side effects include: Constipation: Oxycodone is a common cause of constipation, which can be severe and lead to other complications. Nausea and vomiting: Oxycodone can cause nausea and vomiting, which can be severe and lead to dehydration. Drowsiness and dizziness: Oxycodone can cause drowsiness and dizziness, which can impair coordination and reaction time. Sedation: Oxycodone can cause sedation, which can make it difficult to stay awake or alert. Respiratory depression: Oxycodone can slow down breathing, which can be life-threatening in severe cases. Addiction and dependence: Oxycodone is a highly addictive drug, and long-term use can lead to physical and psychological dependence. Tolerance: Over time, the body may become tolerant to oxycodone, meaning that higher doses are needed to achieve the same pain relief. Withdrawal symptoms: If oxycodone is stopped abruptly, withdrawal symptoms may occur, including anxiety, restlessness, muscle aches, and nausea.

A label of a prescription medicine

Description automatically generated with medium confidence

[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.. 

Scene 14

Lovenox or Enoxaprin Classification: Anticoagulant Purpose/Mechanism of Action: Prevention of DVT, PE, VTE Dosage: 40 mg/0.4ml Subcutaneous Injection Every Day Contraindications: Active major bleeding: Lovenox should not be used in patients with active major bleeding, as it can increase the risk of bleeding. History of heparin-induced thrombocytopenia (HIT): HIT is a condition in which the body's immune system attacks platelets, leading to a decrease in platelet count. Lovenox should not be used in patients with a history of HIT within the past 100 days or in the presence of circulating antibodies. Known hypersensitivity to enoxaparin or its ingredients: Patients with known hypersensitivity to enoxaparin or any of its ingredients should avoid using this medication. Adverse Reactions and Side Effects: Lovenox can cause a range of adverse reactions and side effects, which can vary in severity and frequency depending on the individual and the dose being used. Some of the most common side effects include: Bleeding: Lovenox can increase the risk of bleeding, which can manifest as bruising, bleeding from cuts or wounds, or more serious bleeding events such as internal bleeding. Pain at the injection site: Pain, redness, or swelling at the injection site is a common side effect of Lovenox. Allergic reactions: In rare cases, Lovenox can cause allergic reactions, which can range from mild skin rashes to severe anaphylaxis. Thrombocytopenia: Lovenox can cause a decrease in platelet count, which can increase the risk of bleeding. Epidural or spinal hematoma: In rare cases, Lovenox can increase the risk of epidural or spinal hematoma, especially when used in conjunction with spinal or epidural anesthesia or puncture. This can lead to serious complications, including paralysis.

A close-up of a syringe

Description automatically generated

[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.. 

Scene 15

Miralax or Polyethylene glycol 3350 Classification: Osmotic Laxative Purpose/Mechanism of Action: It works by drawing water into the colon, which softens the stool and stimulates bowel movements.  Dosage: 17 grams daily mixed in 8 oz water or juice. Contraindications: Bowel obstruction: MiraLax should not be used in patients with known or suspected bowel obstruction. Inflammatory bowel disease: Patients with inflammatory bowel disease, such as ulcerative colitis or Crohn's disease, should use MiraLax with caution and under the guidance of a healthcare professional. Severe kidney disease: Patients with severe kidney disease should avoid MiraLax, as it can worsen electrolyte imbalances. Hypersensitivity: Patients with known hypersensitivity to polyethylene glycol or any of the ingredients in MiraLax should avoid using this medication. Adverse Reactions and Side Effects: While MiraLax is generally well-tolerated, some common side effects may occur: Gastrointestinal discomfort: This may include bloating, gas, and abdominal cramps, especially when starting a new course of treatment. Electrolyte imbalances: Long-term or excessive use of MiraLax can lead to electrolyte imbalances, particularly in patients with kidney disease. Allergic reactions: In rare cases, MiraLax can cause allergic reactions, such as rash, hives, or difficulty breathing.

A box of medicine with a purple label

Description automatically generated

[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.. 

Scene 16

A person pointing at a food pyramid

Description automatically generated

A collage of several images of a person lying on a couch

Description automatically generated

[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.. 

Scene 17

CHEST PHYSIOTHERAPY (OPT)
HELPS WITH IMPAIRED mucus CLEARANCE
* POSTURAL DRAINAGE
DIFFERENT POSITIONS to-ts min
USING GRAVITY HELP CLEAR LUNGS
* PERCUSSION
* VIBRATION
* SHAKING
CLIENT
FORCEFULLY
COUGHS AFTER
ACAPELLA
E VICE

[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.. 

Scene 18

A poster with icons on it

Description automatically generated with medium confidence

Patients should be educated on Smoking Cessation (Dangers of 2nd Hand Smoke) Influenza Vaccination Pneumococcal vaccination for at risk patients Handwashing Medication Compliance Contacting provider for follow-up and changes

[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.. 

Scene 19

Case Wrap Up 1 – Presented by Student
(what actually happened)

1.Discuss interventions which were included in the client’s plan of care. Supplemental Oxygen Encourage Fluid Intake Incentive Spirometer Controlled Coughing Semi-Fowlers for Better Oxygenation Give Deltasone, Oxycodone, Ancef, Lovenox, and Miralax as Prescribed. Monitor Patient Vital Signs Q4H and as Needed

[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.. 

Scene 20

Case Wrap Up 2 – Presented by Student
(what actually happened)

2.Discuss outcomes and their evaluation Oxygen saturation improved from 91% to 97% Respirations decreased from 24 to 18 breaths per minute Temperature cooled from 102.6 degrees to 99 degrees Blood Pressure trended downward from 127/94 to 119/72 Patient’s pleuritic pain goal met. Inflammation and infection improving. Patient is breathing better and producing less mucus.
 3.Discuss opportunities for improvement in the plan based on outcomes
 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. 

Scene 21

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

Grand Rounds Project

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

avatar

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.

During the recent clinical rotation at C-H-M 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.

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.

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, F-L-U--, 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.

D B  is a 45-year old white female. She is a Preschool Teacher who received a BA in Early Childhood Education at U-N-C-G-. 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 U-S 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 S-T-D's 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.

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 5 milligrams 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.

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.

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. 4 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 J-V-D--. No signs of D-V-T--. 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.

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 4 push was the antibiotic prescribed. D B 's W-B-C was 19.6 initially, which is elevated.  An elevated W-B-C 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 (C-R-P--) 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.

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.

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.

Oxycodone is an opioid analgesic that binds to opiate receptors in the C-N-S 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  milligrams 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.

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.

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.

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.

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.

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 C-D-C 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.

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.

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.