Diagnosis:
ASPIRATION PNEUMONIA
Chelsea, Elisha, Jessica, Lisa, Morgan
Case Information








27 year old, male
Admitted with uncontrollable fever
Transferred from long term care facility
Hx. of gunshot wound to left chest resulting
in cardiac arrest
Developed hypoxic encephalopathy
Has tracheostomy and gastronomy tubes
Hx. of MRSA
Devoted family
Chelsea, Elisha, Jessica, Lisa, Morgan
Assessment





Thin, cachetic man
Moderate respiratory distress
Unresponsive to voice, touch, painful stimuli
VS: T=40°C, P=120, R=30, SpO₂=90%
Crackles and scattered wheezes in upper left lobe




Serum albumin 2.8g/dl
WBC count 1.8x10⁹/L
Sputum specimen thick, green and foul smelling; cultures pending
ABG: pH 7.29, PaO₂80mmHg, PaCO₂40mmHg, Bicarbonate 16
mEq/L
 Stool culture positive Clostridium difficile
 Chest x-ray: infiltrate in left upper lobe; no pleural effusions noted
Chelsea, Elisha, Jessica, Lisa, Morgan
What is it?
Aspiration Pneumonia
Chelsea, Elisha, Jessica, Lisa, Morgan
Aspiration Pneumonia
Pathophysiology
 Aspiration pneumonia is caused by the abnormal entry of
secretions or substances into lower airway. These
substances them provide an environment for bacteria to
grow. There are four stages of aspiration pneumonia
pathophysiology and they are as follows:




Congestion: when bacteria reach alveoli the organisms multiply
and fluid flows out of the alveoli
Red hepatization: massive dilation of capillaries and alveoli are
filled with bacteria, organisms, neutrophils, red blood cells and
fibrin
Grey hepatization: blood flow decreases and leukocytes and
fibrin accumulate in the affected part of the lung
Resolution: complete resolution and healing occur if there are no
complications
Chelsea, Elisha, Jessica, Lisa, Morgan
What is it?
Hypoxic Encephalopathy
Chelsea, Elisha, Jessica, Lisa, Morgan
Hypoxic Ecephalopathy
Pathophysiology
 Hypoxic encephalopathy is a condition in which the entire
brain does not receive enough oxygen, but isn’t completely
deprived
 Within as little as five minutes of oxygen deprivation, brain
cells can begin dying.
The disease can also cause long-term damage including:




Mental retardation
Delayed development
Seizures
Cerebral palsy
 Severe oxygen deprivation can result in:
 Coma
 Lack of brain stem reflexes (breathing and responding to light)
 Only blood pressure and heart function reflexes are functioning
Chelsea, Elisha, Jessica, Lisa, Morgan
What is it?
Clostridium difficile
Chelsea, Elisha, Jessica, Lisa, Morgan
Clostridium Difficile
Pathophysiology










Most serious cause of antibiotic associated diarrhea
Most common symptoms are watery diarrhea, fever, and abdominal pain or
tenderness
When the C diff bacteria, that normally reside in the body become overgrown, it can
cause severe infection of the colon, colitis, and eradication of the normal gut flora by
antibiotics
The overgrowth is harmful because the bacterium releases toxins that can cause
bloating, constipation, diarrhea, and abdominal pain
Can be flu- like symptoms
Discontinuation of the causative antibiotic is often curative
If it becomes more serious, treatment by oral admin of metronidazole or vancomycin
Typical antibiotics that cause C diff are: ampicillin, amoxicillin, and cephalosporins.
Some less common causative antibiotics are: penicillin, erythromycin, trimethoprim,
and quinolones
Some that rarely cause C diff are: tetracycline, metronidazole (Flagyl), and
gentamicin
Chelsea, Elisha, Jessica, Lisa, Morgan
Tracheostomy Tube
 A tube inserted into the trachea to allow for a
patent airway.
 It is inserted below the larynx and as a result
the vocal chords no longer function
Chelsea, Elisha, Jessica, Lisa, Morgan
Gastrostomy Tube
 A tube inserted directly into the stomach
 Nutrition is administered totally through this
tube. The patient takes nothing by mouth
 A P.E.G tube is a Percutaneous Endoscopic
Gastronomy tube. This refers to how the tube is
inserted
Chelsea, Elisha, Jessica, Lisa, Morgan
Lab Values
What does it all mean?
Chelsea, Elisha, Jessica, Lisa, Morgan
Lab Values
 Serum Albumin
 Pt. Value: 2.8 g/dL
 Normal Range: 3.4-5.4 g/dL
 Protein in highest concentrations in plasma – main transport
protein
 Values affected by synthesis, distribution, and degradation
processes

Decreased levels maybe due to inadequate production, excessive loss
 To determine if a patient has liver, kidney disease or if not
enough protein is being absorbed by the body Indicates
nutritional status, hydration, chronic disease
Chelsea, Elisha, Jessica, Lisa, Morgan
Lab Values
 White Blood Cells
 Pt. Value: 18000 µL (18 x 109/L)
 Normal Range: 3.8-10.8 x 109/L
 Neutrophils, eosinophils, basophils, monocytes,
lymphocytes produced in bone marrow – body’s
defense system
 Life span of cell is 13-20 days, old cells destroyed by
lymph system and excreted in feces
 Increased count: leukocytosis
 Decreased count: leucopenia
Chelsea, Elisha, Jessica, Lisa, Morgan
Lab Values
 Arterial Blood Gas
 Evaluates respiratory function
 Determines: acid-base balance, if patient is in a respiratory
or metabolic imbalance
 Pt. pH: 7.29
 Normal Range: 7.35-7.45
 Changes in ratios of free H+ to bicarbonate result in
compensatory response from: lungs (respiratory) or kidneys
(metabolic)
Chelsea, Elisha, Jessica, Lisa, Morgan
Lab Values
 Arterial Blood Gas
 Pt. PaO2: 80 mmHg
 Normal Range: 80-95 mmHg
 Used to calculate hemoglobin saturation and
availability of O2 for critical organs
 With PaCO2, used to measure O2 gradient of
alveolar-arterial gradient indicating
effectiveness of gas exchange
Chelsea, Elisha, Jessica, Lisa, Morgan
Lab Values
 Arterial Blood Gas
 Pt. PaCO2: 40 mmHg
 Normal Range: 35-45mmHg
 Important indicator of ventilation:
 Conditions that interfere with normal breathing causes CO2 to be
retained in blood
 Conditions that increase breathing rate will cause CO2 to be
removed from alveoli more rapidly than it is produced resulting in
alkaline pH
 Level controlled primarily by lungs therefore is respiratory
component of acid base balance
Chelsea, Elisha, Jessica, Lisa, Morgan
Chelsea, Elisha, Jessica, Lisa, Morgan
Arterial Blood Gas
Metabolic Together Respiratory Opposite
pH
pCO2
pO2
HCO3-
Uncompensated
Decreased
Increased
Normal
Normal
Compensated
Normal
Increased
Increased
Increased
Uncompensated
Increased
Decreased
Normal
Normal
Compensated
Normal
Decreased
Decreased
Decreased
Uncompensated
Decreased
Normal
Decreased
Decreased
Compensated
Normal
Decreased
Decreased
Decreased
Uncompensated
Increased
Normal
Increased
Increased
Compensated
Normal
Increased
Increased
Increased
Acid-Base
Disturbance
Respiratory
Acidosis
Respiratory
Alkalosis
Metabolic
Acidosis
Metabolic
Alkalosis
NURSING DIAGNOSIS
Chelsea, Elisha, Jessica, Lisa, Morgan
Impaired gas exchange r/t to collection
of mucus in airways and inflammation of
airways and alveoli
 Objective Data
 PaO2 80 mmHg
 Pa CO2 40mmHg
 Respiratory Rate of 30
 Heart Rate of 120
Chelsea, Elisha, Jessica, Lisa, Morgan
Impaired gas exchange r/t to collection
of mucus in airways and inflammation of
airways and alveoli
 Interventions
 Assess respirations
 Monitor changes in vital signs
 Assess skin for cyanosis
 Monitor ABGs and oxygen saturation
 Maintain oxygen administration device as ordered
 Anticipate need for intubation if condition worsens
 Expected Outcomes
 Patient maintains optimal gas exchange as evidenced
by eupnea and normal ABGs
Chelsea, Elisha, Jessica, Lisa, Morgan
Ineffective airway clearance r/t to
increased sputum due to pneumonia
 Objective Data
 Respiratory Rate 30
 O2 Saturation 90%
 Chest auscultation revealed crackles and scattered
wheezes in the left upper lobe
 Chest x-ray; infiltrate in left upper lobe
 Interventions
 Assess respiratory movements and use of accessory




muscles
Assess sputum color, amount, and odor and report changes
Auscultate lung sounds
Monitor pulse oximetry
Monitor chest x-ray reports
Chelsea, Elisha, Jessica, Lisa, Morgan
Ineffective airway clearance r/t to
increased sputum due to pneumonia
 Interventions






Sit the patient up in bed
Maintain adequate hydration
Use humidity
Assist with oral pharynx suctioning if necessary
Provide oral care
Consult respiratory therapist for chest physiotherapy
and nebulizer treatments
 Expected Outcomes
 Patient airway is free of secretions as evidenced by
eupnea and clear lung sounds
Chelsea, Elisha, Jessica, Lisa, Morgan
Infection r/t to aspiration from
tracheotomy
 Objective Data
 Temperature 40˚C
 O2 Saturation 90%
 Crackles and scattered wheezes heard throughout
lung fields
 WBC 18000/μl
 Sputum specimen: thick, green colored, foul smelling
 Chest x-ray: infiltrate in left upper lobe
 Interventions
 Assess vital signs, monitor temp
 Obtain sputum for culture and sensitivity
 Monitor lung sounds
Chelsea, Elisha, Jessica, Lisa, Morgan
Infection r/t to aspiration from
tracheotomy
Interventions
 Monitor WBC
 Assess hydration
 Monitor pulse oximetry
 Monitor chest x-ray reports
 Administer antimicrobial agents
 Use appropriate therapy for elevated temperatures;
antipyretics, cold therapy
 Isolate patients as necessary after review of culture and
sensitivity
 Expected Outcomes
 Patient experiences improvement in infection as evidenced
by normo-thermia, normal WBC count & negative sputum
culture report on repeat culture
Chelsea, Elisha, Jessica, Lisa, Morgan
Imbalanced Nutrition: less than body
requirements r/t gastronomy tube, inability to
swallow and diarrhea r/t C.Difficile
 Objective Data
 Cachetic appearance
 G-Tube in situ
 Positive Clostridium Difficile stool culture
 Nursing Interventions
 Ensure feeding schedule is maintained
 Ensure continued support from Registered
Dietician
 Check placement and patency of tube
 Measure amount of feeding exactly
Chelsea, Elisha, Jessica, Lisa, Morgan
Imbalanced Nutrition: less than body
requirements r/t gastronomy tube, inability to
swallow and diarrhea r/t C.Difficile
 Interventions
 Monitor lab values (electrolyte levels, hematocrit,
hemoglobin, blood glucose, and total protien)
 Treat C.Difficile appropriately
 Expected Outcomes
 Pt. will attain an increased nutrition status as
evidenced by body weight will be within 10% of
ideal body weight for his age and height
Chelsea, Elisha, Jessica, Lisa, Morgan
Infection r/t antibiotics
 Objective Data





History of MRSA in sputum
Admitted because of uncontrollable fever
Stool culture positive for Clostridium difficile
WBC count 18,000/ul (18 x 109/L) (normal 3.8-10.8 x 109/L)
Temperature 1040F (40oC)
 Interventions
 Note risk factors causing the infection (prolonged antibiotic
use, weakened immune system, other infections
 Stress proper hand hygiene by all caregivers and family
members
 Use isolation precautions (gown and glove for c.diff but if
MRSA is in sputum then everyone needs to mask as well)
Chelsea, Elisha, Jessica, Lisa, Morgan
Infection r/t antibiotics

Interventions
 Provide information such as pamphlets or handouts to family on the
pathophysiology of c diff and ways to reduce spread of infection
 Maintain sterile technique for all invasive procedures
 Encourage position changes to prevent any further complications
 Administer antibiotics as indicated
 Expected Outcomes

Family of patient will verbalize the understanding of the use of disease
precautions and the importance of them during the first day of care.
 Family will identify interventions to prevent the spread of infection
during the first couple days on the unit
 Family will demonstrate techniques, lifestyle changes to promote safe
environment upon discharge
Chelsea, Elisha, Jessica, Lisa, Morgan
Risk for deficient fluid volume r/t
C.Diff
 Objective Data
 Stool culture positive for C.Diff
 Interventions
 Monitor urine output, intake, and record on data





sheet, and observe color and odor of urine
Weigh daily (same time and scale)
Evaluate lab tests such as: electrolytes, blood
urea, creatinine, total protein)
Evaluate nutritional status
Assess vital signs (temp, pulse, and resps, BP)
Watch for changes in usual function
Chelsea, Elisha, Jessica, Lisa, Morgan
Risk for deficient fluid volume r/t
C.Diff
 Interventions
 Administer fluids and electrolytes as indicated
 Educate patient and family on factors related to occurrence
of deficit
 Modify care plan if patient is not getting the nutrients he
needs
 Expected Outcomes
 Patient will maintain stable vital signs, urine output, skin
turgor, and moist mucous membranes throughout
admission
 Will verbalize understanding of causative factors and
purpose of interventions when LOC is appropriate
 Patient will demonstrate behaviors to monitor and correct
this deficit
Chelsea, Elisha, Jessica, Lisa, Morgan
Risk for impaired skin integrity
r/t C.diff
 Objective Data
 Stool culture positive for c.diff
 Interventions
 Assess circulation and sensation
 Watch for redness or non blanching skin around




bony prominences
Teach patient the importance of good peri-care
Note any odors coming from wounds
Inspect skin on a daily basis
Keep perineum is clean and dry, and teach client
how to manage incontinence
Chelsea, Elisha, Jessica, Lisa, Morgan
Risk for impaired skin integrity
r/t C.diff
 Interventions
 Maintain cleanliness of bedding so pt is not soiled for a prolonged
amount of time
 Reposition client q2h so skin breakdown will not occur
 Prevent any shearing or tearing of skin if transferring or from
movement
 Assess client psychological status for risks of feeling helpless
 Expected Outcomes
 Patient will participate in preventative measures and treatment
program while in care
 Patient will maintain optimal nutrition and physical well being
while in care
 Patient will verbalize feelings of increased self- esteem and
ability to manage situation upon discharge
Chelsea, Elisha, Jessica, Lisa, Morgan
Discussion Questions
 What types of infectious disease precautions
should be taken related to Sam’s hospitalization?
 To prevent to spread of any disease in a facility, staff





should practice scrupulous hand hygiene
Patients with diarrheal illnesses should be isolated.
Gowns & gloves should be worn by all personnel
attending to the infected patients.
With the possibility of MRSA, masks should also be
worn
Linens should be disinfected. Surfaces potentially
infected be clostridium spores should be treated with
bleach
Personal care items should not be shared or reused
Chelsea, Elisha, Jessica, Lisa, Morgan
Discussion Questions
 What clinical manifestations of aspiration
pneumonia did Sam exhibit? Explain their
significance.







Temperature of 40°C
Crackles and scattered wheezes in left, upper lobe
X-ray showed infiltrate in left, upper lobe
Respiratory rate of 30
SpO₂ of 90%
Green, thick, fowl smelling sputum
Elevated WBC
Chelsea, Elisha, Jessica, Lisa, Morgan
Discussion Questions
 What antibiotic medication is likely to be
prescribed?
 Patients with mild to moderate c diff. typically
improve with oral metronidazole or vancomycin.
 More severely infected patients may need
infusions of vancomycin directly into the GI tract.
 Metronidazole is also highly effective in treating
lower respiratory tract infections such as
pneumonia
Chelsea, Elisha, Jessica, Lisa, Morgan
Discussion Questions
 What other clinical issues need to be
addressed regarding his care?
 Skincare – risk for breakdown
 Hydration – increased requirement r/t diarrhea
 Oral care deficit r/t tubing, decreases fluid intake
 Impaired coping - Family coping
 Changed may be required in long term facility
Chelsea, Elisha, Jessica, Lisa, Morgan
Discussion Questions
 What family interventions would you initiate?
 Education re: good hand hygiene, infection




control precautions (isolation). This will limit the
spread is C Diff.
The family should avoid visiting while they are sick
Family support systems – Initiate contact with
support group for children with brain injury
Respite care
Stress management techniques
Chelsea, Elisha, Jessica, Lisa, Morgan
Chelsea, Elisha, Jessica, Lisa, Morgan