Pneumonia

Low complexity — Respiration

Goals

  1. Recognise respiratory insufficiency based on pneumonia and apply nursing interventions accordingly.
  2. Recognise and describe the compensatory mechanisms in respiratory insufficiency.

Anamnese

  • Name: Mr van den Braak
  • Age: 69 years
  • Family: Married
  • Occupation: Retired civil servant
  • Cultural: Catholic

AMPLE

A: Iodine

M: Acetylsalicylic acid - Pantoprazole

P: COPD Gold I - Inguinal Hernia

L: Unknown

E: Increasing dyspnoea

SBAR

S: Mr van den Braak has been admitted with increasing shortness of breath. For the past few days he has also been coughing. He now reports that he is becoming increasingly breathless.

B: Mr van den Braak is a 69-year-old man with a history of COPD Gold I and inguinal hernia.

A: See ABCDE

R: Please assess the patient using ABCDE and apply interventions where necessary.

Situation at the start of scenario

A: Clear, alert. Breathless.

B: RR 23 breaths/min, symmetrical thoracic excursions, mildly increased work of breathing, using accessory breathing muscles, normal jugular veins, rhonchi over the lower lung fields, saturation 94%.

C: Greyish colour, CRT 2 sec, HR 103 bpm regular, normal regular pulse, peripherally lukewarm and clammy, BP 123/61 mmHg.

D: Alert on AVPU, glucose 4.8, pupils PEARL.

E: Temp 38.3°C, no oedema or other abnormalities. Urine output: spontaneous 250 ml 3 hours ago.

Situation at the end of scenario

A: Clear, alert. Increasingly breathless and exhausted.

B: RR 31 breaths/min, symmetrical thoracic excursions, increased work of breathing, using accessory breathing muscles, normal jugular veins, rhonchi over the lower lung fields, saturation 85%.

C: Greyish colour, flushed cheeks, CRT 3 sec, HR 112 bpm regular, normal regular pulse, peripherally lukewarm and clammy, BP 105/54 mmHg.

D: Alert on AVPU, glucose 4.9, pupils PEARL.

E: Temp 38.9°C, no oedema or other abnormalities.

Recommendations

  • Chest X-ray
  • Blood cultures