M.F. is a 37-year-old male presenting to the Emergency Department with dypsnea at rest that has been present for two to three weeks. His condition has worsened over the past two days. He presented with rapid respirations, complaints of periodic confusion, nasal flaring, and irritability. He had an occasional nonproductive cough and was afebrile. The chest x-ray showed bilateral effusion and possible pericardial effusion.
This patient is non-compliant with hemodialysis. On admission to the Emergency Room he had an elevated blood urea nitrogen and creatinine.
Primary Diagnosis and Priority Secondary Diagnosis
M.F. was admitted to the hospital with a primary diagnosis of pneumonia and a secondary diagnosis of chronic renal failure.
Patient History
M.F. has a history of failed renal transplants times two. He also has severe pulmonary hypertension and chronic heart failure. M.F. is non-compliant with his dialysis; he is supposed to have dialysis three times a week. He currently only goes twice per week. The patient is a smoker of one half pack per day and at this time has no plans to quit. He lives with his fiancée, who is present at the patient’s bedside.
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PATHOPHYSIOLOGY OF THE PRIMARY AND PRIORITY SECONDARY DIAGNOSIS
Pneumonia is an excess of fluid in the lungs resulting from the inflammatory process. Inhaling infectious organisms or agents that irritate the lungs can trigger inflammation. The inflammation occurs in the alveoli, bronchioles and interstitial spaces of the lungs. Organisms multiply within the alveolar spaces causing an immune response. White blood cells migrate to the area causing local capillary leak, edema, and exudates. These fluids collect in and around the alveoli, thickening the walls and thus reducing gas exchange. This leads to hypoxia. If the organisms move into the blood stream sepsis results.
The fibrin and edema cause a stiffening of the lungs. This stiffening reduces lung compliance, decreasing the lungs vital capacity. The inflammation of the alveoli causes collapse, further reducing the oxygenation of the blood.
People develop pneumonia when their immune systems are unable to combat the virulence of the invading organisms. Bacteria, viruses or fungi can cause pneumonia. Inhalations of toxic gases or aspiration are among other causes of pneumonia (Ignatavicius & Workman, 2006).
Patients with pneumonia have flushed cheeks, bright eyes, and an anxious expression. They may have pleuritic pain or discomfort, myalgia, headache, chills, fever, cough, tachypnea, tachycardia, and sputum production. Crackles are heard when there is fluid in the interstitial and alveolar spaces. Wheezing may be heard when there is inflammation and exudates in the airways. These patients may be hypotensive as a result of vasodilatation and dehydration.
Chronic renal failure is an irreversible kidney injury. This disease is progressive and ends with the kidney function being too poor to sustain life. The first sign is diminished reserve. In this stage there is no build up of metabolic wastes in the blood. The unaffected nephrons can compensate for the injured nephrons. As renal damage increases systemic blood pressure increases, causing increased glomerular pressure, which will damage more nephrons. As more nephrons are damaged the patient progresses to renal insufficiency. This stage has a build up of metabolic waste in the blood stream. Levels of blood urea nitrogen and creatinine increase, the kidneys are no longer able to maintain hemostasis.
Three main causes of renal failure include diabetes mellitus, hypertension, and glomerulonephritis. Polycystic kidney disease, a hereditary renal disorder, in adults can lead to chronic renal failure.
Chronic renal failure can cause lethargy, seizures or coma. The patient is at risk for fluid overload, hypertension or heart failure. They may also have breath that smells of urine, shortness of breath or tachypnea. In later stages the patient may experience anemia or abnormal bleeding. As kidneys fail the patient may have oliguria. The skin may become itchy or develop a layer of crystals called uremic frost (Ignatavicius & Workman, 2006).
M.F. suffers from shortness of breath, due to increased fluid build up. The fluid builds in his lungs from his chronic renal failure, giving bacteria a place to multiply and causing the immune inflammatory response.
ACTUAL OR POTENTIAL IMPACT OF RELEVENT MEDICAL HISTORY ON THE PRIMARY DIAGNOSIS AND PRIORITY SECONDARY DIAGNOSIS
M.F. has a history of chronic renal failure. He also has a history of non-compliance with his dialysis. When M.F. does not get his dialysis he is at risk for fluid overload. This fluid builds up aggravating his hypertension and his chronic heart failure causing an increase in his pulmonary hypertension. By increasing the fluid in his lungs he decreases his gas exchange causing hypoxia. When the body senses hypoxia it starts to shut down the kidneys, causing a further fluid to build up and the decrease in the other functions of the kidney. One of which is production of erythropoietin. Since the kidneys are not producing this hormone, his body is not producing red cells, causing anemia. M.F. now further decreases his oxygenation levels, which could lead to a decrease in his level of consciousness, causing lethargy and confusion. M.F. had a low hemoglobin level that required treatment in the hospital (see medical management section).
MEDICAL MANAGEMENT: PNEUMONIA
Medical interventions for pneumonia include obtaining a sputum specimen for culture, a chest x-ray to look for areas of increased density, a complete blood count to identify white blood cells and red blood cells and hemoglobin for anemia, arterial blood gases, pulse oximetry for oxygenation. They could also include a blood urea nitrogen level to monitor for dehydration. Blood culture specimen to rule out sepsis. Monitor for signs and symptoms of infection.
M.F. had a slightly elevated white blood cell count (n=5.0-10.0) that ranged from 10.3 to 11.3 on discharge. His hemoglobin (n=14-18) was low upon admission at 7.9; he was given two units of packed red blood cells. His hemoglobin was still low upon discharge, at 10.9, but the patient was not lethargic, confused or short of breath.
X-ray on discharge showed a decrease in the size of infiltrates. M.F. remained afebrile throughout his admission. Upon discharge he was able to ambulate 50 yards, without any signs of distress. He had two negative blood cultures this admission.
To decrease the amount of fluid being retained M.F. was encouraged to follow a renal healthy diet. This would include foods low in protein, sodium and phosphorous (Medical College, n.d.). As kidney function declines these products build up in the blood stream. In order to lower the strain on his kidneys, M.F. was given instructions on foods that meet these criteria. M.F. was also encouraged to attend his dialysis three times per week, as directed by his physician. Hemodialysis is the most common type of dialysis. It uses a filter to remove waste products from the blood stream. It then returns the cleaned blood back to you (Castner, 2008).
NURSING INTERVENTIONS
Textbook recommendations for nursing interventions include cough and deep breathing, use of incentive spirometer, to improve lung compliance. It recommends monitoring vital signs and breath sounds, to assess for improvement of infection. Also recommended is adequate hydration to thin secretions.
M.F. was encouraged to cough and deep breath every hour. He was very lethargic on day one and did not try more than twice. He did increase his attempts on day two. He was given instruction on the incentive spirometer, and was encouraged to use this every hour. He made no attempts on day one. On day two he was able to raise the level to 750mm for three seconds. He increased his efforts and was able to keep the level up for four seconds and repeat this five times each hour upon discharge. The patient’s lung sounds cleared from crackles to clear by discharge. The patient’s respiratory rate returned to between 18-20 breaths per minute upon discharge. M.F. was kept to an 1800 ml per day fluid restriction, due to his increased fluid volume. He remained afebrile throughout his stay. He had a non-productive cough upon admission; this did not clear during his hospital stay.
PHARMACOLOGICAL MANAGEMENT
Treatment options include antibiotics to stop the spread of infection. Bronchodilators may also be used to improve gas exchange. The use of oxygen management is encouraged to increase oxygenation of the blood.
M.F. was on two liters of oxygen via nasal cannula and was able to maintain his pulse oximetry at a level between 92-95%. Upon discharge his pulse oximetry showed 95% on room air. He was started on Avelox (antiinfective) intravenously, and then changed to oral upon discharge. He remained afebrile throughout hospital stay. His white blood count rose slightly, but no other signs of bacterial infection was noted.
PROVIDER AND MANAGER ROLE: NURSING CARE PLAN
“P” Impaired gas exchange
“R” Ventilation-perfusion imbalance
“C” decreased level of consciousness, dypsnea at rest, decreased oxygen saturation <90%
Goal statement
The patient will show improving lung fields and remain free of respiratory distress, as evidenced by clearing chest x-ray and improved oxygen saturation levels by discharge.
Nursing interventions
The nurse will monitor patient’s respiratory rate, depth and effort including use of accessory muscles, nasal flaring and abnormal breathing patterns. The nurse will encourage the patient to cough and deep breath. The nurse will teach and encourage the use of the incentive spirometer hourly.
Evaluation of progress toward patient goal
M.F. had a hard time complying with the nursing interventions.
When using the incentive spirometer his lung sounds went from crackles to clear. His respirations went from 28 breaths per minute to 18. He maintained a pulse oximetry of between 92-95% on 2 liters of oxygen. He was able to ambulate in the hallway without respiratory distress. The chest x-ray taken on the day of discharge showed a decrease in the infiltrates in the patient’s lungs. This patient met his goals upon discharge.
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PROVIDER AND MANAGER ROLE
Role of the Multi-Disciplinary Team
M. F.’s care depended on the ward clerks to order the appropriate tests at the appropriate times. It also included the ancillary services to do the tests as ordered. A nutrition consult was ordered to teach proper diet for a patient that has chronic renal failure. A mental health consult was ordered to evaluate the patient for depression. Also a social worker talked to the patient about his need for transportation to dialysis upon discharge. The discharge planner was also helpful in making dialysis appointments for this patient.
Provider of Care Role
As provider of care I monitored the patient’s vital signs, paying particular notice of his temperature to monitor for infection. I also evaluated M.F.’s breath sounds, noting improvement daily. I gave the patient his medications on time. I also encouraged the patient to cough and deep breath and use his incentive spirometer. I assisted M.F. in ambulation when needed.
Manager of Care Role
As manager of care for this patient I needed to instruct him on the use of his incentive spirometer and the importance of using this equipment to increase his breathing ability. I also monitored his laboratory and radiology results to be sure these were done as ordered. I made sure all the doctors orders were noted in a timely manner and carried out as instructed. I gave this patient his discharge instructions and made sure he was knowledgeable about his diet. I answered any question M.F. had on the information given to him during his admission to the hospital.
Growth in the Manager of Care Role
I was able to see the importance of recognizing the affect of all co-morbidities of the patient. For each disease process there is an effect on other systems, and each of these effects must be taken into account when treating the patient.
When teaching this patient I also was learning the things needed to help in achieving a healthier lifestyle for this patient. This helped me develop a knowledge base that I can build upon. Since this patient was not receptive to instruction, I had to find ways to get him to comply with his orders. I learned to depend on others on my team to help get the job done.
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