In the following pages, the case study of Mr. N will be presented with a diagnosis of pneumonia. Pneumonia is an infection of the lower respiratory tract. It can be caused by viral, bacterial, fungal, protozoal or parasitic infections (Brashers, 2006). Pneumonia can be community acquired, called community acquired (CAP). It can be acquired in a retirement home (NHAP). Pneumonia can also be contracted in hospital and this type of pneumonia is known as a hospital-acquired infection. Mr. N was diagnosed with right upper lobe pneumonia for the initial diagnosis. Say no to plagiarism. Get a tailor-made essay on “Why violent video games should not be banned”?Get the original essayMr. N is a young, white, Christian, upper-middle class male, 36 years old. The patient is a non-smoker. He is married, has 2 children and is expecting a third child. He presented to the hospital complaining of acute fever, chills, rigors, pleuritic chest pain, coughing, and excessive vomiting. This man was writhing in pain, retching and vomiting excessively. Our main goal was to make him comfortable so we could take care of him after receiving him from the emergency MICU. He had attended a doctor's appointment before admission and was referred by his endocrinologist. Laboratory tests ordered from a CMP, CBC, blood cultures X 2; and urinalysis were obtained and sent to the laboratory for processing. A chest x-ray was performed by radiology in the emergency room. Mr. N was placed on a dilaudid pain pump due to excessive pain complaints and a history of chronic pain. Oxygen at a rate of 2 L via nasal cannula was placed on the patient. Respiratory treatments were initiated every 4 hours. Mr. N was encouraged to use his incentive spirometer 10 times every 2 hours. He was encouraged to wear his SCD for circulation and to turn, cough, and deep breathe frequently. The patient was placed on NPO status due to excessive vomiting. His previous TPN prescription was restarted with an IV of normal saline at 100 cc/hour. The patient was asked to keep the head of the cord at 30 degrees or more. He has a history of lupus, Sjögren's syndrome, diabetes, malnutrition, gastroparesis with chronic vomiting, recurrent infections, mainly pneumonia. The patient had been hospitalized for aspiration pneumonia three weeks before admission. This young man has had multiple admissions and treatments. He had spent 164 days in the hospital a few years before this hospitalization. Most hospitalizations were for acute pancreatitis and chronic pancreatitis, considered a secondary problem to lupus. He traveled to Mexico and Russia for stem cell treatments to combat chronic inflammation secondary to lupus and Sjögren's syndrome, at the encouragement of Dr. Bayer, a strong supporter of Stemedica. Stemedica Cell Technologies, Inc., is believed to be transforming regenerative medicine through the development and manufacturing of adult and biologic tolerant ischemic stem cell products (Stemedica Cell Technologies, 2007-2014, p. 1 ). N had undergone pancreatic biopsies in Illinois to try to find the cause of all his illnesses. That biopsy sent him into his first episode of acute pancreatitis and his health has never been the same. He had undergone two abdominal operations before his admission. The first was a duodenojejunostomy to attempt tube feeding due to asignificant weight loss due to gastroparesis. At the time of this surgery, the patient had been diagnosed with SMA syndrome. SMA syndrome is also known as superior mesenteric artery syndrome. SMA is a rare acquired disorder in which acute angulations of the SMA cause compression of the third portion of the duodenum between the SMA and the aorta, leading to obstruction (Archana, Gisel, & Bouras, 2005, p. 1). His gastroparesis was also thought to be from lupus and diabetes. Her second surgery was performed by Dr. Langley the previous winter. The patient said that the surgeon did not have a name for this operation. This was also an attempt to relieve vomiting and differently promote gastric motility from the stomach to the intestine. Since this operation, the patient's mother died suddenly and her vomiting was not relieved by the operation. In fact, the situation was getting worse. He had a right subclavian central line port in place due to receiving NPWT at home. His medications include: prednisone 5 mg orally once daily, zofran 4 mg orally every 6 to 8 hours for nausea; Plaquinil 400 mg once orally twice daily; Hydrocodone 5 to 10 mg every 4 to 6 hours for pain; Salogen 5 mg orally four times a day; Lyrica 600 mg, one orally two to three times a day; Creon 500 lipase units/kg orally with meals/snacks, Humalog insulin pump, Dexilant 60 mg once daily and Topamax 200 mg orally twice daily. Mr. N's vital signs were obtained. He had a blood pressure of 200/90, a pulse of 148 beats per minute; a respiratory rate of 32 breaths per minute and pulse oximetry on room air was 88%. Its temperature is 102 degrees Fahrenheit. N was awake, alert and oriented to person, place and time. His pupils were 3 mm, accommodated and responsive to light. S1 and S2 heart tones were audible with no murmurs or additional heart tones noted. The patient's lungs showed decrease in all lung fields with scattered rales. A greater decrease in the right upper lobe of the lung was noted. Bowel sounds were hypoactive in all four quadrants. The abdomen was soft, nondistended, and tender to palpation. All peripheral pulses were palpable at 2+. Generalized edema is noted. His dressing at the right subclavian central line site was clean, dry, and intact. The insertion site showed slight redness but no warmth was noted. The patient was not ambulatory at that time due to pain, vomiting, and discomfort. Lab results revealed a potassium of 3.2. The white blood cell count was 19.0. There was a leftward shift in leukocytes. The hemoglobin was 7.8 and the hematocrit was 28.7. Urinalysis was normal. Chest x-ray revealed scattered infiltrates throughout with greater consolidation noted in the right upper lobe. Blood cultures the next morning were positive for yeast. Host defenses against lung infections are influenced by inherited genetic components of inflammation, as well as our body's ability to fight disease and specific lung defense processes (Brashers, 2006). When acquiring bacterial pneumonia, the organism is often aspirated, inhaled, or spread into the bloodstream from other sites of infection. The upper respiratory tract is essential for resisting infections. The ability of saliva, cough, gag reflex and IgA antibodies inthe mucosa can be suppressed by diseases, smoking, poor immunity and endotracheal intubation. The lower respiratory tract has cilia in the mucous membranes that attempt to expel contaminants from the lungs. . Surfactants cover the alveoli and reduce tension; preventing the cells from collapsing. This allows oxygen to penetrate the lung lining and pass into the blood. Macrophages are important cells of the immune system that are created in response to infection or by accumulating damaged or dead cells. Phagocytosis of macrophages and leukocytes is another lower respiratory response to fight infection. Macrophages and leukocytes engulf the opposing pathogen. Cell-mediated immunity is the activation of lymphocytes and the destruction of intracellular microbes (Kumar, Abbas, Fausto, & Aster, 2010). Humoral immunity is the activation of B lymphocytes and the elimination of extracellular germs (Kumar et al., 2010). Both cellular and humoral immunity are defenses against offending lower respiratory tract agents. Some of these defense mechanisms may be impaired by decreased consciousness, smoking, cystic fibrosis, chronic bronchitis, immunosuppression, intubation or prolonged bed rest (Brashers, 2006). The dust cells or monocytes in the lungs live on the surface of the lungs and clean them. particles such as dust or micro-organisms. They constitute a primary defense system against invasion of the lower respiratory tract. Every day, the dust cells clear the respiratory tract of the incriminated organisms without creating a significant inflammatory reaction. If the bacteria is too large and capable of causing disease by breaking down the host's protective mechanisms, the macrophage recruits leukocytes and triggers the inflammatory response by releasing cytokines. Cytokines are proteins released by immune cells and act on other cells to coordinate appropriate immune responses. This response leads to inflammation. Inflammation causes ventilation-perfusion mismatch and results in hypoxemia. Apoptosis of lung cells occurs with hypoxemia. Apoptosis is the process of programmed cell death in the body. This action helps destroy any incriminated agent such as bacteria, tuberculosis, influenza, fungal infections of the lungs. The action of apoptosis is beneficial in fighting infections, but it also plays a role in lung injury. The infection may remain in the lungs or lead to sepsis, meningitis, endocarditis and/or systemic inflammatory response syndrome (SIRS) (Brashers, 2006). Lupus is an autoimmune disease. This means that the body's natural defense system, the immune system, attacks healthy tissue instead of just bacteria and viruses. This causes inflammation. Lupus affects the lungs, muscles, brain, heart and kidneys. Sjögren's syndrome is an autoimmune disease in which the glands that produce tears and saliva are destroyed. The disease can affect other parts of the body, including the kidneys, lungs and pancreas. Insulin-dependent diabetes mellitus, now known as type 1 diabetes mellitus, is a known autoimmune disease that results in the destruction of insulin-producing cells. This young man's overactive immune system attacked his pancreas, causing diabetes. Chronic inflammation causes infection. His body is chronically inflamed by his overreactive immune system. He has an answerdamaged immune system. Since Sjögren's syndrome can actually affect one's lungs; the surfactants in his lungs may be less; therefore decreasing oxygenation. High glucose levels are caused by hormones produced to fight disease. Stress and illness cause high blood sugar. Mr. N's body is under chronic stress and managing his blood sugar levels was difficult. Afterwards, receipt of a positive yeast blood culture; the central line was interrupted and sent to culture. The patient continued to experience low oxygen levels and began to have an altered level of consciousness. He was sent for a chest CT scan and it revealed right upper lobe pneumonia and left upper and lower lobe embolic pneumonia. The central line was positive for yeast. A picc line was placed for IV access. Antifungals have been added to current broad-spectrum IV antibiotics to combat bacterial and fungal infections. Reduced mortality is observed with rapid initiation of antibiotic treatment. Corticosteroid therapy was initiated intravenously to combat his inflammatory response. Steroid and antibiotic therapy improve gas exchange and patient outcomes. An insulin infusion with hourly blood glucose checks was started to regulate blood sugar. This would facilitate healing and fight infections. A potassium bolus was initiated and administered every six hours for a K level of 3.2 to prevent arrhythmias. After his vomiting subsided, the patient was able to eat a clear liquid diet. Lovenox injections were started for DVT prevention. Patient breathing treatments, incentive spirometry, and turning, coughing, and deep breathing techniques were strongly encouraged. Several nursing diagnoses must be addressed with a diagnosis of pneumonia; including the patient's knowledge of the deficit, risk of dehydration, unbalanced diet, acute pain, activity intolerance, risk of infection, impaired gas exchange and, last but not least, ineffective clearance of the respiratory tract. Airway management should always be addressed first. Ineffective airway clearance is the first nursing diagnosis that should be addressed during MN's hospitalization. The airway, in cases of pneumonia, could be compromised due to the presence of secretions. The respiratory rate would be affected. The change in the patient's oxygen/carbon dioxide ratio due to decreased oxygen and poor gas exchange due to exudates on the alveoli results in an increase in respiratory rate. Hyperventilation begins to cause an increase in the tidal volume of air to facilitate the absorption of more oxygen. Bronchospasms occur and can cause dyspnea, immobile secretions, and infection. The nurse makes several attempts to create effective breathing. Mr. N and his family learned the importance of carrying his oxygen and cooperating with ordered breathing treatments. This would increase his oxygen absorption and increase healing efforts. Upon admission, the patient was encouraged to change positions frequently, maintain the head of the bed at 30 degrees or higher, and use his incentive spirometer every two hours as ordered. The patient was asked to undergo respiratory therapy. The patient has a history of aspiration and has continued to vomit, again putting him at higher risk for aspiration. All of these interventions will facilitate airway exchange. The family and the patientlearned the importance of all these techniques to contribute to the well-being of the patient. If antibiotics are initiated within the first four hours of hospitalization, the risk of death is significantly reduced. This patient's labs show a significant decrease in hemoglobin and a major leftward shift in white blood cells increases the opportunity for bacteria to invade and set up camp in a specific part of the body. In this case, the patient's initial infection was right upper lobe pneumonia. Embolic pneumonia was the second diagnosis. The center line was removed due to the cultured tip revealing yeast growth. Yeast from the catheter projected infected emboli into the lungs. Infection is a top priority in this case. IV antifungal therapy increased his chances of survival along with the administration of antibiotics. Good universal precautions are essential with this patient. His immune system is constantly compromised and proper hand washing with him, staff and his family would help his overall health. A dietitian was consulted to increase nutrition due to vomiting and history of malnutrition. Proper administration of TPN and nutritional intake play an important role in infection control. Controlling pain and nausea would be important to maintain affective breathing, proper gas exchange, and resolve the infection. The patient's treating physician continued to prescribe his medications at home upon admission. Dilaudid was prescribed for adequate pain control. Zofran PO was replaced by IV. The healthcare staff reported to the medical team that zofran was not helping her nausea. IV phenergan was tried without results. IV Compazine was prescribed and nausea control was achieved. Pain and nausea contributed to inadequate breathing and gas exchange. The risk of aspiration from vomiting increases the risk of infection. Mr. N's medical team, nursing staff, dietitian, and family worked diligently to resolve the pain and nausea by communicating appropriately with each other. The expected results for Mr. N and the maintenance of his airway were achieved thanks to the doctor's orders, the nursing and respiratory staff initiated, administered and followed up on the medications and treatments ordered. Continued teaching to the patient, family and each other created a very positive outcome for MN. Breathing difficulties were relieved and the airway was maintained throughout his hospitalization. The patient was able to verbalize his understanding and demonstrate deep breathing techniques. This intervention, encouraged by all the staff involved, made it possible to obtain good oxygenation and relieve hyperventilation. The patient remained free of cyanosis and was able to establish a normal respiratory rhythm. With all medications, interventions, and the patient's ability to remain compliant, ease of breathing was achieved. The medications prescribed for pain, nausea and airways as well as the treatments carried out by all were successful in maintaining adequate airways; good gas exchange and efficient breathing. Mr. N's wife was able to intervene by noticing a decrease in the patient's level of consciousness and a bi-pap was ordered for one day of his hospitalization. This helped the patient when he was compromised and facilitated adequate gas exchange. He was able to return to a nasal cannula the next day and the necessary airway was maintained. The patient's wife was able to encourage him to wash and disinfect his hands..