Case Based Presentation on

Bacterial Pneumonia

Presented to:
Hajra Sarwar
MScN BScN
LSN, UOL.
Presented By:

Faiza islam:70106373
Objectives:
At the end of session we will be able to:
 Definition
 Pathophysiology
 Symptoms
 Causes
 History of Patient
 Nursing physical assessment
 Medical management
 Nursing Care Plan
 Recommendations
Demographic Data:

 Age 84years old

 Sex Female
 Diagnose Bacterial
Pneumonia
Patient History Data:
Chief Complain:
 Provided by patient’s home caregiver: ―Mrs. I. is confused and
very sick. She was up most of last night coughing.
History of present illness:
 Approximately three days ago, the patient developed a cough
that has gradually become worse and she now has difficulty
catching her breath.
 The caregiver also reports that the patient was confused last
night and nearly fell while going to the bathroom.
 The patient has been coughing up a significant amount of
phlegm that is thick and green in color.
 She has no fever. The caregiver has become concerned by the
patient’s reduction in daily activities and an inability to get rid
of her ―cold.‖
Main arguments that nurse focus
on:
 Assess respiratory symptoms. Symptoms of fever, chills, or
night sweats in a patient should be reported immediately to
the nurse as these can be signs of bacterial pneumonia.
 Assess clinical manifestations. Respiratory assessment
should further identify clinical manifestations such as
pleuritic pain, bradycardia, and tachypnea, and fatigue, use
of accessory muscles for breathing, coughing, and
purulent sputum.
Continue…
 Physical assessment. Assess the changes in temperature and
pulse; amount, odor, and color of secretions; frequency
and severity of cough; degree of tachypnea or shortness of
breath; and changes in the chest x-ray findings.
 Assessment in elderly patients. Assess elderly patients
for altered mental status, dehydration, unusual behavior,
excessive fatigue, and concomitant heart failure
Bacterial Pneumonia:
Pneumonia is a common lung infection where the lungs’ air sacks
become inflamed. These sacs may also fill with fluid, pus, and
cellular debris. It can be caused by viruses, fungi, or bacteria. This
article is about pneumonia caused by bacteria.

(Debra Sullivan,2018)
Causes And Symptoms:
 Each type of pneumonia is caused by different and several
factors.
 Community-Acquired Pneumonia:
 Streptococcus pneumonia. This is the leading cause of CAP
in people younger than 60 years of age without
comorbidity and in those 60 years and older with
comorbidity.
 Hemophilic influenza. This causes a type of CAP that
frequently affects elderly people and those with comorbid
illnesses.
 Mycoplasma pneumonia.
Continue
Hospital-Acquired Pneumonia
 Staphylococcus aureus. Staphylococcus pneumonia occurs
through inhalation of the organism.
 Impaired host defenses. When the defenses of the body
are down, several pathogens may invade the body.
 Comorbid conditions. There are several conditions that
lower the immune system, causing bacteria to pool in
the lungs and eventually result in pneumonia.
 Supine positioning. When the patient stays in a
prolonged supine position, fluid in the lungs pools down
and stays stagnant, making it a breeding place for
bacteria.
Symptoms:
 Bluish color to lips and fingernails.
 Confused mental state or delirium, especially in
older people.
 Cough that produces green, yellow, or bloody mucus.
 Fever.
 Heavy sweating.
 Loss of appetite.
 Low energy and extreme tiredness.
 Rapid breathing.
Pathophysiology:
 Pneumonia arises from normal flora present in patients
whose resistance has been altered or from aspiration of
flora present in the oropharynx. An inflammatory reaction
may occur in the alveoli, producing exudates that
interfere with the diffusion of oxygen and carbon
dioxide. White blood cells also migrate into the alveoli
and fill the normally air-filled spaces. Due to secretions
and mucosal edema, there are areas of the lung that are
not adequately ventilated and cause partial occlusion of
the alveoli or bronchi.
Continue
 Hypoventilation may follow, causing ventilation-perfusion
mismatch. Venous blood entering the pulmonary circulation
passes through the under ventilated areas and travels to the
left side of the heart deoxygenated. The mixing of
oxygenated and poorly oxygenated blood can result to
arterial hypoxemia.
History:
 Approximately three days ago, the patient developed a
cough that has gradually become worse and she now has
difficulty catching her breath. The caregiver also
reports that the patient was confused last night and
nearly fell while going to the bathroom. The patient has
been coughing up a significant amount of phlegm that
is thick and green in color. She has no fever. The
caregiver has become concerned by the patient’s
reduction in daily
activities and an inability to get rid of her ―cold.‖
Past medical history:
 Patient is Tobacco dependence 64 years.
 Chronic bronchitis for approximately 13 years
 Urinary overflow incontinence × 10 years
 HTN 6 years ago, BP has been averaging 140/80 mm Hg with
medication
 Mild left hemiparesis caused by CVA 4 years ago
 Depression 2 years ago, Constipation 6 months ago,
and Influenza shot 3 months ago.
Family and Socio Economic History:
Family history:
 (+) for HTN and cancer
 (-)for CAD, asthma, DM
Social history:
 Patient lives with caregiver in patient’s home
 Smokes 1/2 ppd
 Some friends recently ill with ―colds‖
 Occasional alcohol use, none recently
 Review of system:
 Difficult to conduct due to patient’s mental state (lethargy
present)
 Patient has had difficulty sleeping due to persistent cough
 Caregiver has not observed any episodes of emesis
but reports a decrease in appetite
 Caregiver denies dysphagia, rashes, and hemoptysis
Treatment
: Treatment for bacterial pneumonia includes antibiotics,

which target the specific type of bacterium causing the
infection. A doctor might also prescribe medications to
ease breathing. Additional medications may include over-
the- counter (OTC) drugs to ease aches and pains, as well
as reducing fever.
 Medication History:
Medication: Rational according to book:
 Atenolol 100 mg po QD  Beta blocker medication
 HCTZ 25 mg po QD  Diuretic medication
 Aspirin 325 mg po QD  Acetylsalicylic
Acid medication.
 Nortriptyline 75 mg po QD  Tricyclic
 Combivent MDI puffs antidepressant
QID
2 (caregiver reports  Ipratropium
patient rarely uses) bromide
 Albuterol MDI 2 puffs QID
PRN
 Docusate calcium 100  Adrenergic receptors
mg po HS agonistic
 Physical Examination
General History:
 She is well groomed and neat.
 Use walker for ambulation.
 She walks with noticeable limb.
 She is a lethargic, frail, thin woman.
 She uses accessory muscles to breath.
 She is tachypnea and has respiratory distress
Conti…
Vital Signs:
 Blood Pressure: 140/80 mmHg has be average
with medication. (HTN).
 Pulse: 95/m and Regular
 Respiratory Rate: 38/m and labored (Tacypnea)
 Temperature: 98.3°F
 Height: 5'101⁄2‖
 Weight: 124 lbs (56kg)
 Body Mass Index (BMI): 17.6
 Saturation (O2): 86% on room air (Low)
Conti…
Skin:
 Warm and clammy
 (-) for rashes
HEENT:
 Fundi without lesions
 Eyes are watery
 Nares slightly flared; purulent discharge visible
 Ears with slight serous fluid behind TMs
 Pharynx erythematous with purulent post-nasal drainage
 Mucous membranes are inflamed and moist
Conti…
Neck:
 Supple (bending or moving easily)
 Mild bilateral cervical adenopathy
 (–) for thyromegaly, JVD, and carotid bruits
Lungs/Thorax:
 Breathing labored with tachypnea
 RUL and LUL reveal regions of crackles and diminished
breath sounds
 RLL and LLL reveal absence of breath sounds and dullness
to percussion
 (–) egophony
Conti:
Cardiac:
 Regular rate and rhythm
 Normal S1 and S2 • (–) for S3 and S4
Abdominal:
 Soft and NT
 Normoactive BS
 (–) organomegaly, masses, and bruits
Genit/ Rect:
 Examination deferred
Conti…
Ms/Ext:
 (–) CCE
 Extremities warm
 Strength 4/5 right side, 1/5 left
side
 Pulses are 1_x0002_ bilaterally

Neuro:
 Oriented to self only
 CNs II–XII intact
 DTRs 2_x0002_
 Babinski normal
 Laboratory Blood Test Results:
Laboratory Blood Test Results

Na 141 meq/L Glu, fasting 138 mg/dL Lymphs 10%

K 4.5 meq/L Hb 13.7 g/dL Monos 3%

Cl 105 meq/L Hct 39.4% Eos 1%

HCO3 29 meq/L WBC 15,200/mm3 Ca 8.7 mg/dL

BUN 16 mg/dL Neutros 82% Mg 1.7 mg/dL

Cr 0.9 mg/dL Bands 4% PO4 2.9 mg/dL

Arterial Blood Gases:

Arterial Blood Gases

pH PaO2 59 mm Hg on PaCO2 25
7.50 room air mm Hg
Urinalysis:

Urinalysis

Appearance: Light yellow Protein Nitrite

and hazy (–) (–)

SG Ketone Leukocyte esterase

1.020 s (–) (–)

pH Blood 2 WBC/RBC per HPF

(–)
6.0
Glucose Bilirubin Bacteria
(–) (–) (–)
Conti…
Urinalysis:
The urinalysis report shows that the appearances of urine is light
yellow and hazy and the other findings are negative. The Ph. of
urine 6.0 is the average urine sample test and 2 WBC/RBC per
HPF show the increase number of WBCs in the urine under a
microscope and a positive test for leukocyte esterase may
indicate an infection or inflammation somewhere in the urinary
tract.
Conti…
Chest X-Rays:
 Consolidation of inferior and superior segments of RLL and
LLL
 Developing consolidation of RUL and LUL
 (–) pleural effusion
 Heart size WNL
Sputum Analysis:
 Gram stain: TNTC neutrophils, some epithelial cells,
negative for microbes
Sputum and Blood Cultures:
 Pending
References:
 Mark Williams; Scott A. Flanders; Winthrop F. Whitcomb (28
September 2007). Comprehensive hospital medicine: an
evidence based approach. Elsevier Health Sciences. pp. 273–.
ISBN 978-1-4160-0223-9. Retrieved 11 November 2010.
 Chalmers JD, Singanayagam A, Akram AR, et al. (October
2010). "Severity assessment tools for predicting mortality in
hospitalized patients with community-acquired pneumonia.
Systematic review and meta-analysis". Thorax. 65 (10): 878–83.
 "Adult pneumococcal vaccination". Current Opinion in
Pulmonary Medicine. 23 (3): 225–230.
Conti…
 Medical Editor: Charles Patrick Davis, MD, PhD. Reviewed
on 3/29/2021
 Reviewed by Carol DerSarkissian on November 09,
2020CDC: ―Pneumonia Can Be Prevented -- Vaccines Can
Help,‖ ―Pneumococcal Vaccination
 Medically reviewed by University of Illinois — Written by
University of Illinois — Updated on September 29, 2018.
 Gupta, R. K., George, R. C., & Nguyen-Van-Tam, J. S. (2008,
August). Bacterial pneumonia pandemic influenza
and planning. Emerging Diseases, 14(8).
Infectious
wwwnc.cdc.gov/Eid/article/14/8/07-0751_article.htm
Conti…
 Johnstone J, Eurich DT, Majumdar SR, Jin Y, Marrie TJ
Long‐term morbidity and mortality after hospitalization with
community‐acquired pneumonia: a population‐based cohort
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 Koivalu I, Sten M, Makela PH. Risk factors for pneumonia
in the elderly. Am J Med 1994;96:313–20.
 1999 Lippincott Williams & Wilkins, Inc.
 Ramirez, J. A., Tzanis, E., Curran, M., Noble, R., Chitra,
S., Manley, A., ... & McGovern, P. C. (2019). Early clinical
response in community-acquired bacterial pneumonia: from
clinical endpoint to clinical practice. Clinical Infectious
Diseases, 69(Supplement_1), S33-S39.
Conti…
 Hopkins E, Sanvictores T, Sharma S. StatPearls [Internet].
StatPearls Publishing; Treasure Island (FL): Sep 14, 2020.
Physiology, Acid Base Balance.
 Yamaguchi M, Minamide Y, Terao Y, Isoda R, Ogawa T,
Yokota S, Hamada S, Kawabata S. Nrc of Streptococcus
pneumoniae suppresses capsule expression and enhances anti-
phagocytosis. Biochem Biophys Res Commun. 2009 Dec
04;390(1):155.