Respiratory Tract Infection – Pneumonia

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Updated: Dec 16, 2022
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A 59 year old Jane Johnson who was suffering from pneumococcal pneumonia was admitted to a hospital . She presents a medical history of 10 year that includes a deaf left ear following a surgical removal of acoustic neuroma . She takes phenytoin Sodium Capsules three times a day for a post surgical seizures disorders . She takes Welbutrin XL (bupropion) for a depression and she also takes analapril (Vasotec) for mild hypertension . Ms. Jane Johnson is admitted for an IV antibiotic and she is allergic to penicillin.


Pneumonia is an acute respiratory tract infection which affects the lungs (World Health Organization, 2009). Pneumonia is caused by different species of microbes; bacteria, virus, fungus as well as inhalation of irritating agents (Ignatavicius, 2006, World Health Organization, 2009). Pneumococcal pneumonia is caused by gram positive cocci bacteria, streptococcus pneumonia (Ignatavicius, 2006). Pneumococcal pneumonia mainly affects adults over 65 years and children under 2 years of age. The population at a high risk of getting pneumococcal pneumonia are people suffering from chronic or severe medical conditions, such as lung, neurologic disorders, and malignance, hospitalized patients, heart or liver disease patients (University of Maryland Medical Center, 2009). Pneumococci are spread through direct contact with respiratory secretions from healthy carriers or sick people (World Health Organization). Other body fluids like blood provide alternative route of transmission.

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Pneumococcal pneumonia symptoms may have a sudden onset. Symptoms may include a severe shaking chill, followed by cough, high fever, chest pain, shortness of breath and rapid breathing. Other symptoms include headache, tiredness, vomiting, nausea, and muscle aches. Adventitious lung sounds resulting from fluid accumulation are common with pneumonia. Diagnoses is done by finding the bacteria in your lung fluid, saliva or blood. pneumococcal pneumonia is preventable through vaccination (World Health organization 2009, Pérez-Trallero, 2003). Symptoms of pneumococcal pneumonia usually disappear within 12 to 36 hours after beginning of treatment .

Psychosocial assessment

As a result of suffering from the various symptoms; left ear hearing deficit, pneumonia, seizures, depression, hypertension as well as social and economic isolation following admission to hospital, the patient may develop anxiety and inability to take care of self. Pneumonia results to shortness of breath and thereby a reduced capacity to perform activities of daily living. The patient lives alone and earns an hourly wage as a waitress. Since pneumonia is an infectious disease, she may be required to absent from work till recovery. Absenting from work implies that she will not be paid since she is an hourly paid worker and as a result she may get stressed up and even more depressed. Shortness of breath and any seizures disorder jeopardizes her life since she lives alone and her children are not available assist her incase of falling unconscious or feebly weak. She needs to have a psychosocial assessment to establish how she is coping with the disease process and also to establish the extent of depression. She requires a more frequent evaluation of blood pressure.

Laboratory assessment

A blood or sputum sample ought to have been evaluated for infection and possibly a culture sensitivity studies conducted. A chest X-ray report would also have illustrated the extent of infection of the lungs. The patient’s blood phenytoin level of 15 mcg /ml compares well with a therapeutic range of 7.5 to 20mcg /ml (Skidmore-Roth, 2009). The patient had an elevated white cell count of 12,000/ml compared to the normal range of 5000 – 10000 /ml (Ignatavicius, 2006). According to Ignatavicius, increased levels of white cell count are associated with infection, inflammation, autoimmune disorders and leukemia. Electrolytes including potassium are normal but the pulse oximetry shows a hemoglobin saturation of 85% which is below normal range of 95%-100%. According to Ignatavicius hemoglobin saturation levels below 94% are common with people having chronic obstructive pulmonary diseases. A hemoglobin saturation level of 90% requires medical attention. The patient had an acute infection and therefore running shortness of breath requiring her to take frequent several breaths; 28 respirations per minute.

Patient specific characteristics

The patient has a diagnosis of pneumococcal pneumonia. She is allergic to penicillinis and she is admitted to the hospital for IV antibiotics indicative of infection. She is placed on cefotetan (Cefotan) 3000mg IV every twelve hours and a daily intravenous dose of 500mg azithromycin (zithromax). The patient has deafness in the left ear following surgical removal of acoustic neuroma her left auditory nerve ten years ago. She also developed seizure disorder secondary to the surgery and she takes the anticonvulsant phenytoin 100 mg three times daily. She takes daily doses of oral bupropion 150 mg for depression. She is mildly hypertensive and she takes vasotec 10mg every morning for the condition. She is an hourly worker and works in customer services as a waitress. Pneumonia is infectious and she could spread the infection to other people. Her children live away from her and she lives alone.

Vital signs

Her body temperature of 39 degrees centigrade is above normal range of 35.8-37.3 (Jarvis, 2008). The elevated body temperature may be as a result of infection; combination therapy of antibiotics like cefotetan, a beta lactam cephalosporing and azithromycin, a macrolide that inhibits 50s ribosomal units and prevents protein synthesis will help to lower infection and possibly have a thermo adjustment. Her systolic blood pressure of 130 need further regular monitoring since it is above normal value of 120 (Lehne, 2007). According to Lehne, Ms. Johnson’s systolic pressure is within prehypertensive range of 120 -139 mm Hg. Her labored respiration rate of 28 per minute is way above the normal range of 12 to 20 respirations per minute. Shortness of breath is likely to induce sympathetic nervous system and possibly increase her heart rate from 90 to above 100 per minute. Her pulse is within normal range (Jarvis, 2008). The patient weighs 65kg and is 5’9” tall giving a basal metabolic index, BMI of 21.1

Current medications

Phenytoin (Dilantin), is an anticonvulsant that inhibits the spread of chaotic electrical activity (seizure) in the motor cortex by raising seizure threshold. Its common side effects include; hypotension, agranulocytosis, aplastic anemia, hirsutism, gingival hyperplasia and Stevens Johnson syndrome (Skidmore-Roth, 2009). The patient should avoid dehydration since the drug has a narrow therapeutic range and the patient should use soft tooth brush because of gingival hyperplasia (Lehne, 2007). Nursing interventions include assessing duration, type, intensity and precipitating factors for the seizure. Blood studies; CBC, platelets should be checked every 2weeks to monitor the extent of agranulocytosis and anemia. To discontinue taking phenytoin, the medication should be tapered. Patient should also be told to take the medication at the same time every day.

Wellbutrin XL (bupropion) 150mg p.o q day

Bupropion is an antidepressant that increases concentration of Dopamine in the synapse by inhibiting its reuptake (Lehne, 2007). High doses of the drug increase the risk of seizures. The therapeutic effects of the drug occur after 2-4 weeks of using the drug. Its common side effects include; seizures, suicidal ideation and auditory disturbances (Skidmore-Roth, 2009). Nurses should assessing if the patient has excessively used OTC stimulants and CNS depressants because they increase the risk of seizures.

Enalapril (Vasotec) 10mg every morning

Vasotec is an antihypertensive that selectively inhibits angiotensin-converting enzyme (Lehne, 2007). Its therapeutic response is to decrease blood pressure. Enalapril causes the following side effects are; dysrythmnia, agranulocytosis, myocardial infarction and renal failure. In order to avert fatalities blood studies must be conducted and the medication should be discontinued if neutrophils are

Cefotetan (cefotan) 3000mg IV q 12 hours

Cefoten is a cephalosporin beta lactam antibiotic that inhibits synthesis of bacterial cell wall. Cephalosporin and penicillin have similarity of the beta lactam ring (Herbert, 2000). According to Herbert, the cross-reaction between penicillin and cephalosporin is rare, the evidence suggests that a cross-reaction between penicillin and cephalosporin is rare and probably not greater no greater than that between penicillin and structurally unrelated antibiotics. Side effects of cefotetan include; renal failure, leucopenia, thrombocytopenia, agranulocytosis, nephrotoxicity urticaria, rash and pururitis. Nursing assessment includes checking for increased BUN and creatinine. Supra infection may be significant and, perineal itching; pain swelling and diarrhea should be reported.

Azithromycin (Zithromax) 500mg IV q day

Zithromax is an antiinfective that is used for mild to moderate infections of the respiratory tract especially for people who are resistant to penicillin (Lehne, 2007).The drug is infused in large volumes of fluids. Its common side effects include; hepatotoxicity, angioedema, palpitations, nausea, vomiting and diarrhea. Nursing considerations include intake and output and monitoring presence of blood in urine, hematuria, hepatic studies including AST, ALT, CBC. Since the drug is eliminated through kidney, NSAIDS and any drugs that reduce renal clearance should be avoided. Bowel pattern should be checked before and during treatment. Respiratory status is important and treatment should be discontinued if wheezing, tightness in chest occurs.

Monitoring and assessment

Managing the diagnoses helps in realizing any permanent changes such as improved oxygen saturation levels, reduction in respiration rate; improved breathing. Progression of disease or recovery process should be assessed through monitoring lab values for WBC and Sputum microscopy to determine presence of infection. Hypertension should be monitored regularly and blood levels of phenytoin should be determined regularly. The patient should have psychosocial assessment on how she is copying with social economic stress. Referral to a social worker should be done or advice on how the patient can secure supplemental funding to compensate for when the patient is admitted /out of work. Phenytoin may cause gingival hyperplasia and the client needs to be educated on how to use soft tooth brush and also monitor for bleeding gums. Vital signs should be monitored to stay within the normal range especially since the patient is at high risk of infections. Liver function tests need to be conducted since azithromycin is hepatotoxicity (Chandrupatla, 2002). Neutrophils counts should she monitored for neutropenia and if neutrophils count get below 1000 cell / mL, enalapril (Vasotec) should be discontinued (Skidmore-Roth, 2009).

The patient should not use salt substitutes when taking vasotec. There was general need to monitor for any allergic reactions from medication as well as contraindications of the medication in use to be sure of effective medical therapy.

The patient needs to be taught about therapeutic effect for wellbutrin (bupropion) which is noted in 2 to 4 weeks from the time treatment starts. A referral to a dietician may also provide additional knowledge on how to manage her disease through proper nutrition. It is advisable to determine the patient`s perception of her illness and involve the family and close associates in adjusting to the changes. Involvement of others would ensure that the client maintains her self identity and self esteem among other people.

The nurse should inform the client to report any bleeding and joint pain which occurs with long therapy for cefotan and also report any fever, fatigue or diarrhea from use of zithromax

Patient Teachings:

Since pneumococcal pneumonia is respiratory illness that could be managed at home, the client’s children who live out of town may experience transport or commuting issues and thereby find it difficult to help their mother. I would suggest that community based care may serve and supplement other options that may be available to her. I suggest that the client needs to be referred to complementary health care professionals such as social workers who would guide her to manage any changes from the community level.

The client will be taught to maintain proper body hygiene and to observe skin integrity to avoid further bacterial infections

  • To report any symptoms of infections like fever, cough or sore throat over the counter drugs should not be used before discussing with a physician, pharmacist or prescriber of current drugs in order to avoid drug interactions.
  • Since the patient is using many medications that have a wide range of side effects, the patient should report any allergies, skin rashes, changes in breathing patterns, fever changes in skin color and texture.
  • The client should discuss when and how to discontinue any medication with the prescriber since medications like phenytoin needs to be tapered off.

The patient needs to be taught:

  • importance of complete dose regimen especially with the antiinfectives.
  • To be carrying an emergency ID stating use of Phenytoin.
  • Patient is notified that if dosage for wellbutrin is exceeded, the risk for seizures is increased.
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