Pneumonia

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