Introduction
Community-acquired pneumonia (CAP) is the most common type of pneumonia impacting the health of many people globally. According to Cao et al. (2017), community-acquired pneumonia refers to the infectious swelling of the lung parenchyma acquired outside hospitals. CAP is mainly caused by a range of pathogens including bacteria, viruses, fungi and parasites. The disease is considered infectious since it can spread easily from one person to another. For instance, when an individual with CAP sneezes or coughs, the infectious pathogens are released into the air and are inhaled by others. Depending on the immune systems of individuals, the pathogens can be eliminated or grow to cause pneumonia (Cedars-Sinai 2020).
The prevalence of community-acquired pneumonia is high among adults across the world, impacting adversely on their normal functioning and routine activities. In Europe, 10 in every 1000 persons are infected with CAP and the prevalence increases with age (Cao et al., 2017). In the United States, the mean incidence of CAP is 2.5/1000 per year in adult patients. In patients aged between 65 and 79 years, the average incidences of CAP is 6.3/1000 while in populations aged 80 years and above, the disease incidence is 16.4/1000 persons per year.
In the US, community-acquired pneumonia remains an important health concern costing the healthcare system and patients millions of dollars annually.
According to Pfuntner, Weir and Steiner (2011), there are approximately 915, 500 episodes of CAP among adults aged 65 years and over in the US and 2011, the medical costs of CAP exceeded 10 billion dollars. In 2017, the number of CAP linked visits to the emergency departments across the country exceeded 1.7 million, further illustrating the danger it portrays to individuals and the healthcare system (Modi & Kovacs, 2020). This paper provides a critical discussion of the nursing assessment, priorities of care and nursing management of a 64-year-old woman diagnosed with community-acquired pneumonia within the first 24 hours of admission.
The Etiology and Pathophysiology of Community-Acquired Pneumonia
Globally, community-acquired pneumonia (CAP) remains the most common cause of death from infectious disease (Cilloniz, Cardozo & Garcia-Vidal 2018). The disease is associated with significant morbidity and mortality rates, especially among elderly populations. In recent years, the disease prevalence has increased globally, resulting in increased hospitalizations. This situation has caused a rise in the medical expenses of patients and strains to the healthcare systems around the world.
Community-acquired pneumonia is commonly caused by the invasion of the lungs by pathogenic microorganisms. The most common cause of this disease is Streptococcus pneumonia (The Mayo Clinic, 2020). This bacterium causes the disease after individuals are exposed to flu and mainly affects the lobe of the lung. CAP caused by this pathogen affects all people regardless of their ages and settings (Cillozin et al., 2011). Another pathogen associated with CAP is Mycoplasma pneumonia. This pathogen is a bacteria-like microorganism that attacks the lungs, producing milder symptoms than those of other pathogens. Community-acquired pneumonia is also associated with viruses and fungi. Some viruses such as influenza cause cold, resulting in pneumonia (Burk et al. 2016). Fungal CAP mainly occurs among individuals with chronic health conditions and compromised immune systems. Such people are susceptible to fungal infections that attack the lungs due to poor immunity.
Pathogenesis
Like other forms of pneumonia, CAP is associated with inflammation of the lung parenchyma following the actions of microbial organisms. These organisms can only cause disease when they reach air sacs. The common channel for reaching this vital part of the lungs is microaspirations of the oropharyngeal excretions (Singh 2012). Once these microorganisms reach the alveoli, they attach the alveolar macrophage, which are the last defence mechanisms of the lungs, causing pneumonia. In cases where the alveolar macrophage cannot control the growth of the microorganisms in the lungs, the lungs develop an inflammatory response characterized by the movement of the white blood cells, lymphocytes and monocytes into the alveolar space.
The aetiology and pathogenesis of community-acquired pneumonia are vital in determining the assessment and management of patients with the condition in clinical settings (Sethi 2019). In this case study, an understanding of the aetiology and pathophysiology of community-acquired pneumonia will influence the clinical assessment and management of Mandeep, a 64-year-old woman diagnosed with CAP on arrival to hospitals.
Nursing Assessment
In clinical settings, nursing assessment is an important step in determining patient illnesses and planning for necessary treatment to improve the health of patients. It encompasses the collection of information on the physical, psychological, spiritual and sociological status of patients (Toney-Butler & Unison-Pace 2020). Nursing assessment is important in healthcare settings, especially for patients presenting with life-threatening conditions such as CAP. Health assessments influence decisions made by practitioners in patient management and nursing interventions. It ensures that healthcare professionals act on the right information while providing patient care, improving the health outcomes for patients in the process (American Nurses Association 2019). In this case, different practices were undertaken by the nurse to assess the patient critically for better care provision and management planning.
History TakingOne way through which the nurse conducted a patient assessment on Mandeep is history taking. When patients are reported to the hospital, nursing practitioners must gather information about the histories to determine their illnesses and the factors in play. According to Fawcett and Rhynas (2012), history taking is an essential component of patient assessment by nursing practitioners and facilitates the delivery of high-quality care. Through history taking, nurses are capable of understanding the complexities and processes involved in the histories of their patients, allowing them to understand the presenting problems. Moreover, history taking allows the nurses to prioritize care and identify the necessary interventions to optimize patient outcomes. In most cases, patient histories are taken within the first 24 hours of arrival of patients in healthcare settings.
In this case, taking the patient’s history on arrival at the hospital was challenging since the patient was unwell and unable to speak in complete sentences and was shivering. However, after the patient was stabilized and admitted, the nurse was able to capture the patient’s history. Among the things that were captured in the patient’s history in this case were; the history of cough, fever and sputum, pleuritic pain and functional or cognitive decline. The nurse also sought information on patient’s history of smoking and alcoholism, and the presence of any chronic health conditions Acquiring this information was important as it helped the nurse to understand the extent of the illness and the risk factors of the patient that continue to support the disease prognosis. This way, the nurse can formulate informed treatment plans for the patient.
- Physical Examination
Another important activity in the nursing assessment that was conducted for this patient within 24 hours was a physical examination. In nursing, a physical examination is important in providing a complete picture of patient condition. Physical examination of patients refers to the process of assessing the anatomic findings through observation, palpitation, percussion and auscultation (Migliore 2018). The physical examination requires patient cooperation and overcoming provider bias as the relationship should be therapeutic and diagnostic. When performed effectively, the physical examination of patients should provide 20% of the data required for patient diagnosis and management (Aldamarchi 2018).
For the case study patient, the nurse engaged in a range of physical examinations to determine the patient’s condition. One of the physical examinations that were conducted in this case is an examination of the respiratory rate of the patient. The respiratory rate of a patient is the number of breaths taken per minute (Elliot 2016). For normal adults, the respiratory rate ranges from 12 to 20 breaths per minute and anything below or above this rate is considered abnormal. Upon admission, Mandeep has a respiratory rate of 27 breaths per minute, indicating the presence of lung infection.
Secondly, the nurse assessed the patient’s pulse rate as part of the physical examination of the patient. Also called the heart rate, the pulse rate refers to the number of heartbeats in a minute. For adults at rest, the normal pulse rate ranges between 60 and 100 beats per minute (The Mayo Clinic 2020). In this case study, the patient recorded a pulse rate of 120 beats per minute which is higher than the required range. This heart rate shows existing stress in the lung, causing an increase in the heart rhythms.
A further physical assessment of the patient showed an elevated temperature of 390C, a blood pressure of 87/40mmHg, oxygen saturation of 89% room air. Under normal circumstances, the levels of saturated oxygen in the blood should be above 93% (Hafen & Sharma 2019). Low levels of oxygen saturation signify low oxygen concentrations. In this case, the patient has an oxygen saturation level of 89%, indicating severe CAP. The high temperature and low blood pressure also show the severity of the disease.
Lastly, as part of the physical assessment of the case study patient, the nurse assessed the capillary refill time and established that it took 5 seconds. According to Jevon and Gallier (2020), capillary refill time refers to the amount of time taken by the distal capillary bed to gain its colour after the application of pressure to it to cause blanching. For normal adults, the capillary refill time is 2 seconds. However, for patients with hypovolemia and hypotension, the capillary bed takes longer to refill. In this case, the patient has a capillary refill rate of 5 seconds, indicating low blood pressure and hypovolemia caused by acute community-acquired pneumonia.
Priorities of Care
After conducting nursing assessments and determining the extent of the disease in patients, nurses must engage in prioritization of care to achieve better patient outcomes. Establishing the priorities of care allows healthcare professionals to focus on what the things that matter most in achieving better patient outcomes to the things that matter the least. It also allows healthcare practitioners to improve their care provision strategies (Leclerc et al. 2020). In the case of Mandeep, the practising nurse engaged in prioritizing certain practices to improve care provision for the patient.
- Airway Management
Upon admission of the patient, the first activity that was conducted by the nurse on duty was airway management. In nursing, airway management is the evaluation, planning and use of medical procedures in maintenance or restoration of ventilation in patients (Goto et al. 2019). In clinical settings, nurses engage in airway management to improve ventilation for critically ill patients with breathing difficulties. Patients with acute CAP experience breathing life-threatening difficulties. Nurses should, therefore, conduct airway management to increase the levels of ventilation and improve patient outcomes.
Since the patient experienced life-threatening breathing difficulties, the nurse used intubation to help the patient to achieve ventilation and normalize her breathing. Intubation encompasses the insertion of an endotracheal tube through the mouth of a patient into the airway to facilitate breathing (Whitlock 2020). Intubation is commonly used to assist patients with severe illnesses who cannot breathe normally due to illness. In this case, the patient reported breathlessness and could not speak well in complete sentences, hence the need for intubation to achieve proper ventilation. Airway management was considered the priority in the management of this patient since the respiratory system is connected with the circulatory system and can have fatal effects if not managed properly.
- Adequate Hydration
After achieving ventilation and ensuring that the patient breathes normally, the next priority of the nurse was adequate hydration of the patient. In nursing, hydration therapy encompasses the administration of electrolyte-packed IV fluids directly into the bloodstream of patients (Cicily, Sams & Gopal 2017). Depending on the patient’s needs, the electrolyte fluids may be enhanced with additives such as calcium, magnesium, sulphates and vitamin B complex. Patients with pneumonia have high rates of dehydration caused by fever. In this case, the patient recorded a temperature of 390C, causing dehydration from increased sweating. Administration of electrolyte-packed fluids to the patient within the first few hours of admission was necessary to curb fever. Moreover, patient hydration was also necessary to thin the sputum removed when coughing. Since the patient was intubated and drinking water was difficult, hydration therapy was considered the best strategy to achieve adequate hydration.
- Pain Management
After achieving patient hydration, the nurse then took measures to manage pain in the patient. In nursing, pain management refers to the process of relieving patients of pain caused by their illnesses. Pain management is important in improving health outcomes for patients. For patients with acute community-acquired pneumonia, pain is inevitable. These patients experience chest pains caused by infection of the lungs. Such pains especially occur when patients cough and worsen as the disease progresses.
To effectively manage pain for the case study patient, the nurse administered ibuprofen to the patient. Ibuprofen is a pain-relieving drug that is taken daily by patients to relieve pain. The drug is available as tablets, capsules, and syrup. The drug works by regulating the hormones that cause pain and swelling in the body and takes 20 to 30 minutes to achieve pain relief if taken orally (Rinott et al. 2020). In this case, the doctor provided the patient with this medication in the first 24 hours of admission to reduce pain. The medication was administered orally after it was pounded and mixed with water. Effectively controlling pain was an important way of reducing the severity of CAP in the patient and achieving better health outcomes. The nurse monitored the patient for adverse effects such as vomiting and high blood pressure.
- Love and Belonging Needs
After ensuring patient stability through airway management, hydration and pain relief, the nurse considered the love and belonging needs of the patient.
An important healthcare need for patients who are critically ill is the feeling of love and acceptance by the family members. According to Maslow’s hierarchy of needs, the love and belonging needs of individuals come third after the physiological and safety needs of patients are fulfilled (Uysal, Aydemir & Genc 2017). As part of fulfilling the love and belonging needs of the patient, the nurse engaged in active listening of the patient to know if there were any discomforts following the treatment provided. Through active listening, the nurse was able to address the complaints of the patient effectively. Apart from actively listening to the patient, the nurse also informed the family members of the patient’s condition and allowed them to see her. Having family members around her during illness improved her mode, positively impacting her health.
Nursing Management
Apart from patient assessment and prioritization of care provision, nursing management is also vital in improving the health outcomes for patients with critical health conditions such as acute CAP. Nursing management encompasses various activities undertaken by nurses and other healthcare professionals to deliver efficient patient care regardless of the changing needs of patients. Nursing management focuses mainly on improving health outcomes for patients by providing quality healthcare services. Effective nursing management also increases the loyalty of patients and their levels of satisfaction with the services provided. In this case, the nurse employed a range of nursing management practices to improve health outcomes for the patient.
- Antibiotic Therapy
One management approach that the nurse used to manage the patient effectively within the first 24 hours of admission into the hospital is antibiotic therapy. For many patients with CAP, the causative agent for illness is not commonly identified in disease diagnosis. Consequently, antibiotic therapy is commonly used in the management of the disease.
Since the first antibiotics that were given to the patient failed to achieve the desired outcomes, the nurse changed the prescription for Mandeep. The nurse provided dual antibiotic therapy to improve the health status of the patient. Specifically, the nurse used a combination of an extended-spectrum β-lactam and a macrolide or an anti-pneumococcal quinolone instead of a monotherapy. According to Caballero and Rello (2011), the combination of the two regimens has the ability to curb the primary causes of community-acquired pneumonia, including the drug-resistant Streptococcus pneumonia, viruses and fungi. For patients with severe CAP, the administration of dual antibiotic therapy is essential since the drugs counter the activities of most of the microorganisms that cause CAP simultaneously. Dual therapies also contribute to faster patient healing than monotherapies. In this case, the application of dual antibiotic therapy enhanced patient recovery. The nurse began administering the dual antibiotic therapy on the first day of admission and continued it for 10 days.
- Cough Management
Another management approach that the nurse used for the case study patient is cough medication. One symptom of community-acquired pneumonia is a persistent cough. Individuals who have this condition cough frequently, hindering them from conducting their normal activities or resting. The situation is worse in severe CAP. Administration of cough medication can help in reducing the frequency of coughs among patients, allowing them to rest. In this case, the nurse provided a mixture of honey and lemon to the patient to help in the management of cough. This way, the nurse managed to control the cough without conventional medication, leading to improved patient outcomes.
Conclusion
Community-acquired pneumonia remains the most common cause of death from the infectious disease globally. The condition occurs outside hospital settings and is caused by various microorganisms, including bacteria, fungi and viruses. CAP mainly affects the adult population due to their compromised immune systems and the existence of underlying health conditions such as heart disease and diabetes. In healthcare settings, nurses play a vital role in the management of patients with acute CAP. They engage in patient assessment, allowing them to have a perfect understanding of the disease history and the risk factors associated with the illness. Nurses also engage in prioritization of care, identifying the activities that need to be performed first to avoid adverse patient outcomes. This way, they can engage in informed planning for the treatment options for patients with CAP. Moreover, nurses perform patient management to improve care provision for patients. Nurses should, therefore, develop the desired skills to enhance care provision for patients with acute CAP.