CASE STUDY: MRS KENNEDY
SERIAL
NUMBER
TOPIC
1
INTRODUCTION
2
EFFECTIVE CARE FOR THE PATIENT
3
MANAGEMENT
4
CONCLUSION
5
REFERENCES
INTRODUCTION
Mrs Kennedy is a 63 year old woman who has been transferred to the medical ward
after spending ten days in the ICU ward. She was suffering from shortness of breath
which was increasing in intensity. While she was admitted, her hypoxia increased to
such an extend that she was provided with ventilatory support. She then developed a
nosocomial infection. She developed lobular pneumonia. Blood and sputum samples
were taken and the results show indicates Methicillin-Resistant Staphylococcus
Aureus (MRSA). The tube was removed yesterday and she has developed a cough
where she produces a thick, yellow sputum and has become febrile. She has a history
of smoking and drinking and her vital signs show no abnormality
EFFECTIVE CARE FOR PATIENT
Pneumonia can be defined as inflammation of the parenchyma of the lung. In Mrs
Kennedy’s case, the anatomic distal portion of the lung is involved. The pathogenesis
is due to Methicillin-Resistant Staphylococcus Aureus (MRSA). MethicillinResistant means that this form of the bacteria is not susceptible to penicillin and its
derivatives. Pneumonia is infective by origin. The organisms reach the lung by four
ways, either by inhalation through the air, or aspiration or due to haematogenous
spread or through direct spread from contiguous site of infection following a
penetration injury. Nosocombial or hospital acquired pneumonia occurs when there is
cough suppression, or due to decreased mucociliary clearance due to anaesthetic
agents or due to aspiration of nasopharyngeal secretions in unconscious patients. Mrs
Kennedy was immobilised and was kept under face mask. Mrs Kennedy also had
many predisposing factors like altered consciousness, chronic venous congestion of
the lungs and I.V. abuse. Also she has a history of smoking and alcoholism and her
age is above sixty years.
The organism responsible for primary pneumonia is Staphylococcus Aureus. The
problem is that there is a risk of developing secondary pneumonia where the lung
becomes diseased. For effective care it is first important to investigate and mark the
extend of the disease. The investigations include a chest x-ray, sputum examination
by gram’s and ziehl – nelson stains, sputum culture, bronchoscopic aspiration culture,
nose and throat swab, blood should be examined for leucocytes, blood culture and
sensitivity tests should be done followed by serological tests. If emphysema or fluid in
the lung is present, pleural fluid aspiration should be done. Blood gas analysis should
also be done. (Godsi, 2010)
Once the tests are performed, it is important to recognise the sign of the disease, as
this helps in assessing the progress of the disease. In the early stages, the respiratory
movements decrease, there is impairment of percussion notes and diminished breath
sounds. As the disease progresses, a pleural rub is felt on the affected side. Later,
signs of consolidation appear along with a high pitched bronchial breathing and
increased vocal resonance. And during resolution, numerous coarse crackles or
crepitations can be heard; this indicates the liquefaction of alveolar exudates.
A good nurse must also be able to recognise the clinical symptoms of pneumonia.
This includes sudden onset of cough and dyspnoea. This was experienced by Mrs
Kennedy. This is followed by tachypnoea where the respiratory rate increases to
more than 30 breaths in a minute. The patient will also experience shaking chills and
rigors. Tachycardia is accompanied by a hot dry flushed face. A high grade fever is
also seen, where the temperature is almost 39 degree Celsius. Mrs Kennedy is running
a temperature of 38.1 degrees. There might also be the occasional vomiting. When the
Mrs Kennedy regains consciousness, she will experience a loss of appetite, body
aches and head aches. Convulsions are also common and a constant, stabbing pain is
felt in the chest which increases with respiration. Central cyanosis is observed in
severe cases. Heamoptysis or blood streaked sputum is also common. General
weakness will also be felt. (Forbes, 2005)
MANAGEMENT
The management is a four fold procedure. Firstly, antibiotics should be prescribed.
They are the main stay of the treatment. They should be administered as soon a the
diagnosis of pneumonia is suspected. In non serious pneumonia, initial treatment is
with amoxicillin 500mg 8 hourly or erythromycin 500 mg 6 hourly or oral
cephalosporine (cefaclor 250mg 8 hourly) should be started. If the patient is seriously
ill or infected with staphylococcus, then ampicillin 0.5-1.0 hourly with flucloxacillin
250-500mg I.V. 6 hourly and gentamicin 60-80 mg every 8 hours I.V. should be
started. The antibiotic therapy should be adjusted after sputum or blood culture and
sensitivity report. The antibiotic choice should be specific to the causative organism.
The antibiotic therapy is the for seven to ten days. Majority of the cases respond
quickly .delay suggests that there is some complication. In severely ill patients, like
Mrs Kennedy, ampicillin or amoxicillin parentlerally remains the drug of choice.
However, Mrs Kennedy, is infected by Methicillin-Resistant Staphylococcus Aureus
(MRSA). So derivatives of penicillin will not work. Intravenous cefotaxime or
ceftriaxone (1 gram 12 hourly) may be employed. Vancomycin , I gram 12 hourly is
used in infections resistant to penicillin or cephalosporin. (Goode, 2009)
Oxygen therapy is only indicated in gravely ill patients. It is to be delivered in high
concentrations through masks. Analgesics help suppress the pleuritic pain. However
the problem, these medicines suppress cough which then delays recovery. There fore
mild analgesics must be used to relive the pain such as paracetemol 500 mg or
mefenamic acid 250-500 mg alone or in combination. Some patients may also require
pethidine 50- 100 mg I.V. or I.M. opiates use must be discouraged as they not only
cause addiction , but also respiratory depression. (McCloud, 2009)
Physiotherapy is the last procedure. Nurses must encourage the patient to cough and
take deep breath as soon as the pleuritic pain disappears. In case of persistent pain,
physiotherapy is combined with analgesics so that the recovery is hastened.
In case of staphylococcal pneumonia, it occurs as primary illness or it is acquired
through haematogenous spread. In this type , patchy areas of consolidation in or more
lobes, breaks down to form thin walled abscesses. The treatment includes intravenous
flucloxacillin 0.5 -1.0 gram every 6 hours. In severe infection , sodium fusidate 500
mg over a period of 6 hourly intravenous may be given three times a day. The therapy
is continued for two weeks.( Wayne, 2008)
CONCLUSION
Mrs Kennedy is a 63 year old woman who has been transferred to the medical ward.
She developed lobular pneumonia. Blood and sputum samples were taken and the
results show indicates Methicillin-Resistant Staphylococcus. The investigations
include a chest x-ray, sputum examination by gram’s and ziehl – nelson stains. The
signs include decrease in respiratory movements, impairment of percussion notes and
diminished breath sounds. The clinical symptoms include tachypnoea ,shaking chills
and rigors. ,a hot dry flushed face, high grade , occasional vomiting, loss of appetite,
body aches and head aches, convulsions and a constant, stabbing pain is felt in the
chest which increases with respiration. Management is intravenous cefotaxime or
ceftriaxone ,1 gram 12 hourly, or Vancomycin , I gram 12 hourly . Oxygen therapy is
only indicated. Mild analgesics must be used to relive the pain such as paracetemol
500 mg. Physiotherapy is encouraging the patient to cough and take deep breaths.
REFERENCES.
Wayne, 2008, “ The American journal of medicine” vol. 2, issue 7. pp. 113
Goode, 2009, “ The Journal on respiratory disorders” vol. 12, issue 6. pp. 874
Forbes, 2005, “ The New England journal of medicine” vol. 5, issue 3. pp. 714
Godsi, 2010, “ The journal of medicine sciences” vol. 4, issue 3. pp. 583
McCloud, 2009, “ The New Zealand journal of medicine” vol. 1, issue 5. pp. 7147