Pneumonia

Goals

1. Recognise respiratory insufficiency in COVID-19 and apply nursing interventions accordingly.
2. Recognise and describe the compensatory mechanisms in respiratory insufficiency.
3. Apply isolation measures in COVID-19.

Anamnese

• Name: Mr van Dalen
• Age: 71 years
• Family: Single
• Occupation: Retired teacher
• Cultural: Not known

AMPLE

A: Unknown

M: Unknown

P: Type II diabetes - hypertension - bronchiectasis - CABG 2x bypass

L: Unknown

E: Increasing dyspnoea

SBAR

S: Mr van Dalen has been admitted with confirmed COVID-19. He has been feeling flu-like for a week and has been admitted for two days with fever and shortness of breath.

B: Mr van Dalen is a 71-year-old man with a history of type II diabetes, hypertension, bronchiectasis and CABG 2x bypass.

A: See ABCDE

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

Situation at the start of scenario

A: Clear, alert. Clearly breathless.

B: RR 25 breaths/min, symmetrical thoracic excursions, increased work of breathing, using accessory breathing muscles, normal jugular veins, rhonchi over all lung fields, saturation 91%.

C: Greyish colour, CRT 2 sec, HR 115 bpm regular, normal regular pulse, peripherally lukewarm and clammy, BP 118/58 mmHg.

D: Alert on AVPU, glucose 7.4, pupils PEARL.

E: Temp 38.4°C, no oedema or other abnormalities. Urine output: spontaneous 300 ml 4 hours ago.

Situation at the end of scenario

A: Clear, alert. Increasingly breathless and exhausted.

B: RR 35 breaths/min, symmetrical thoracic excursions, increased work of breathing, using accessory breathing muscles, normal jugular veins, rhonchi over all lung fields, saturation 80%.

C: Greyish colour, flushed cheeks, CRT 3 sec, HR 115 bpm regular, normal regular pulse, peripherally lukewarm and clammy, BP 100/48 mmHg.

D: Alert on AVPU, glucose 8.1 mmol/l, pupils PEARL.

E: Temp 39.1°C, no oedema or other abnormalities.

Recommendations

• Chest X-ray
• Blood cultures