- Review the resources for this module and reflect on the different health needs and body systems presented.
- Review your peer’s case studies discussions.
- Consider how you will practice critical decision making for prescribing appropriate drugs and treatment to address the complex patient health needs in the patient case study.
Read a selection of your colleaguesâ€™ responses and respond to two of your colleagues, and provide recommendations for alternative drug treatments to address the patientâ€™s pathophysiology. Be specific and provide examples.
*Use 3 resources for each student response.
*Provide sources that are no older than 5 years.
Original Patient Case Study Peers Reviewed and Discussed:
HH is a 68 yo M who has been admitted to the medical ward with community-acquired pneumonia for the past 3 days. His PMH is significant for COPD, HTN, hyperlipidemia, and diabetes. He remains on empiric antibiotics, which include ceftriaxone 1 g IV qday (day 3) and azithromycin 500 mg IV qday (day 3). Since admission, his clinical status has improved, with decreased oxygen requirements. He is not tolerating a diet at this time with complaints of nausea and vomiting.
Ht: 5â€™8â€ Wt: 89 kg
Allergies: Penicillin (rash)
*First Student Review Discussion on the Original Case Study:
Pneumonia case study
Community-acquired pneumonia (CAP) is a widespread category of infectious diseases that are responsible for major global health and economic burdens. Each year, more than 4 million outpatient patients are treated for community-acquired pneumonia (CAP) in the United States (US) and nearly 80 percent are treated on an outpatient basis (Harnett, 2017).CAP is the leading cause of hospital admissions, morbidity, and mortality in developed countries (especially the elderly). Of all CAP patients, those aged 65 or older account for only one-third but account for more than half of all health costs as a result. Chronic obstructive pulmonary disease ( COPD) is characterized by a long-term deterioration of airflow, resulting in shortness of breath, cough, and sputum output. (Lui, Han & Lui, 2018). COPD is one of the most common comorbidities in CAP patients characterized by recurrent respiratory symptoms (Pletz, Welte, Kolditz & Ott, 2016).
Brief Summary of patientâ€™s Case
The patient is a 68-year-old male who has been diagnosed with community-acquired pneumonia for the past 3 days. The health history of this client includes COPD, HTN, hyperlipidemia, and diabetes. The patient is on day three two empiric antibiotics (ceftriaxone 1 g IV daily and azithromycin 500 mg IV daily). The health condition of the client has improved after admission with reduced oxygen requirements. The patient is not tolerating anything orally at this time and he complains of nausea and vomiting. The patient height is 5â€™8â€, weight is 89 kg. He has an allergy to Penicillin which results in a rash.
In the scenario, the patient is responding well to the latest antibiotic treatment, as shown by a reduction in WBC count from 18.2 on admission to 14.6 at present (normal range is between 4.0-11.0). It is also satisfying that the client’s O2 saturation is now 92% on room air, compared to 90% while on oxygen 4 liters upon admission. His lab results are not too alarming. The results are slightly elevated as expected due to him having an infection. The main issues of concern here are the client is unable to tolerate a diet due to nausea and vomiting, an increase in temperature, and the continuation of antibiotics to treat pneumonia.
The patientâ€™s antibiotic regime is consistent with what is recommended by the Infectious Diseases Society of America (IDSA) (Prina, Otavio, & Torres, 2015). Initial empiric antimicrobial therapy should be started before laboratory findings have been obtained to guide more specific therapy. Often, a beta-lactam mix. (ceftriaxone 1 g IV q24h or cefotaxime 1 g IV q8h or ceftaroline 600 mg IV q12h) plus azithromycin 500 mg IV q24h is compatible with the IDSA recommendations for clients with comorbidities such as COPD and diabetes. This treatment should be maintained for a minimum of 5 days, the person should be afebrile for 48-72 hours, have steady blood pressure, a sufficient oral intake, and have room air oxygen saturation. In addition to these conditions, the temperature of the client should be below 100.9o F before transitioning to oral antibiotics (Prina et al, 2015). Zofran or some other antiemetic drug would be considered if the client is still unable to handle meals on the 5-day mark. However, we expect nausea to resolve while the antibiotics work to cure lung infection. If this client follows all conditions and retains them for 24 hours, antibiotic therapy will be switched from IV to oral therapy (Prina et al, 2015).
As a result, if the client can withstand oral antibiotics and his temperature drops below 100.9, discharge should be considered. In the end, the client will be released and sent home with a course of oral antibiotics. Since the client has a PCN allergy, the client will start using oral fluoroquinolone. The efficacy and tolerability of levofloxacin 500 mg daily for 10 days in CAP patients is well known (Prina et al, 2015).
The patient has COPD, which is significant comorbidity to remember. Also, COPD increases the risk of developing CAP (Pletz et al, 2016) COPD is, however, a normal and significant predisposing comorbidity in patients who develop CAP and also increases the clinical symptoms of CAP patients. Although this can complicate care, it usually does not affect the prognosis (Liu, Han, & Liu, 2018).
An effective patient education plan for this patient will be for the disease management nurse to visit this patient before discharge and provide the patient with handouts as well as a community-acquired pneumonia educational session. Tips for promoting faster recovery should also be addressed. This includes: having plenty of rest, deep breathing exercises, hand washing, coughing/sneezing etiquette, drinking plenty of water, and maintaining a healthy diet. Strategies to prevent contracting pneumonia should also be included, such as: having a flu vaccine, avoiding smoking, controlling pre-existing respiratory conditions ( e.g. asthma or COPD), obtaining a pneumonia vaccine, and remaining healthy.
Harnett, G, (2017). “Treatment of Community-Acquired Pneumonia: A Case Report and Current Treatment Dilemmas”, Case Reports in Emergency Medicine, vol. 2017, Article ID 5045087, 7 pages, 2017. https://doi.org/10.1155/2017/5045087
Liu, D. S., Han, X. D., & Liu, X. D. (2018). Current Status of Community-Acquired Pneumonia in Patients with Chronic Obstructive Pulmonary Disease. Chinese medical journal, 131(9), 1086â€“1091. https://doi.org/10.4103/0366-6999.230727
Pletz, M. W., Rohde, G. G., Welte, T., Kolditz, M., & Ott, S. (2016). Advances in the prevention, management, and treatment of community-acquired pneumonia. F1000Research, 5, F1000 Faculty Rev-300. https://doi.org/10.12688/f1000research.7657.1
Prina, E., Ranzani, O. T., & Torres, A. (2015). Community-acquire pneumonia. Retrieved from: https://doi.org/110.1016/S0140-6736(15)60733-4
*Second Student Review Discussion on the Original Case Study:
Immediate Health Care Need of the Patient
According to the case study, patient has not been tolerating diet, this is because of nausea and vomiting. This may be because of many things, which include been placed on antibiotic for few days (Relist, 2018) or some other related condition that has not being discovered by the provider. It is imperative for the provider to conduct additional physical examinations this may include kidney, Ureter, and bladder (KUB). This is necessary to determine if nausea and vomiting is been caused by antibiotic or is cause by any other unknown factors.
Patient hydration status must be confirmed. It was established in the case study that patient has being nauseating and vomiting in the past few days, there is tendency for patient to be dehydrated at this time. It imperative to get patient well hydrated during his recovery period. This will be of great advantage to the patient, it will maintain complete homeostasis for patient and at this same time loosen the secretions and help patient to improve on his COPD complications. In addition to this, it will be of great assistance to the patient to facilitate better breathing by clearing his airways(Ausmed ,2017) The intake and output of the patient must be measure and monitor at all times to maintain adequate hydration for the patient.
Another important area I would like to pay attention to is the length of IV antibiotic therapy. The infectious Disease society of America (IDSA) recommends treatment of CAP patients who are admitted into the hospital with five to seven days of empiric antibiotic (File,2020). It was recommended by the IDSA to re-evaluate patient in fifth or seventh day before one can stop the administration of antibiotic. According to the objective data provided, patient is clinically unstable (HR >100 RR>24 and oxygen saturation is 90% on room air during admission.
The first line of treatment is to stop nausea and vomiting. Therefore, Metoclopramide 10mg IV Q6H to control patient nausea and vomiting if the cause of the nausea and vomiting cannot be established. (Entringer,2019)
More so, if patient cannot take fluid through is mouth, the patient will be placed on IV fluid with normal saline 0.9 at 75ml/hr.
I would strongly recommend that patients should continue with current antibiotic until it reaches 7 days. patient should be re-evaluated to establish the current patient COPD conditions to know the next line action to prevent exacerbation. This is important to prevent any medical complication.
According to the case study, one of patient diagnosis is diabetic. Patient should be placed on sliding scale insulin to keep patient blood sugar under control. Checking patient blood sugar regularly before each meal will help to stabilize patient blood sugar.
COPD patient should be encouraged to use incentive spirometer. This will help patient to keep his airway open and prevent mucus from clog on patient lung and impaired breathing.
I will try to enlighten the patient about the treatment he has received including the administered medications.
Patient will be instructed to take metoclopramide before meal to prevent nausea and vomiting and to enable him keep food in his stomach to maintain homeostasis and well hydrated. In addition to this patient will be given comprehensive education about pneumonia and how it can be prevented. Patient will be advised to get pneumonia vaccine before discharge to lower the risk of recurrent of pneumonia. Patent will be encouraged to as question to establish understand of the education and teaching.
Ausmed. (2017). Pneumonia Symptoms, Signs and Treatment. Retrieved July 26, 2020, from https://www.ausmed.com/cpd/articles/pneumonia-explained
Baer, S. L. (2019). Community-Acquired Pneumonia in Adults. Retrieved July 26, 2020, from https://www.cedars-sinai.org/health-library/diseases-and-conditions/c/community-acquired-pneumonia-in-adults.html
Braeken, D., Franssen, F., SchÃ¼tte, H., Pletz, M., Bals, R., Martus, P., & Rohde, G. (2014). Increased Severity and Mortality of CAP in COPD: Results from the German Competence Network, CAPNETZ. Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation, 2(2), 131-140. doi:10.15326/jcopdf.2.2.2014.0149