Respond to these discussion posts, in 125 words and at least one reference.
1. What major outcomes do you expect to achieve for this patient?
In the case of Mr. Z, the major outcomes expected are improved ventilation and oxygenation of tissues, normal ABGs, optimal gas exchange, absence of respiratory distress, and prevention of severe complications. (Eshwara et al., 2020)
What interventions must be initiated to monitor, prevent, manage, or eliminate the problems and risks identified?
Due to increased respiratory rate of 40 breaths per minute, multilobar infiltrates, and COPD, severe community-acquired pneumonia (SCAP) and systemic infection would be imminent if left untreated. Antibiotic therapy specific to addressing streptococcus pneumoniae must be initiated immediately as well as oxygen therapy appropriate for comorbidity of chronic obstructive pulmonary disease (COPD). Fluid resuscitation should be used if systolic pressure is less than 90 mmHg or diastolic below 60 mmHg. Frequent reassessment should be done to evaluate present treatment modalities and to detect changes in current condition. (Eshwara et al., 2020; Metlay et al., 2019)
What interventions should be initiated to promote optimal functioning, safety, and well-being of the patient?
Until symptoms of respiratory distress subside, patient should be on continuous monitoring of vital signs and oxygen therapy. Additionally, fall precautions should be implemented and bed rest encouraged (Pneumonia in Adults, 2019). Nicotine replacement therapy and in-patient counseling should be considered as symptoms of severe tobacco withdrawal may become evident during hospitalization (Wolfenden et al., 2003).
What possible learning needs do you anticipate for this patient?
The patient should be educated on how COPD and smoking can contribute and exacerbate community-acquired pneumonia. The typical course of expected improvement once discharged should also be discussed so that the patient understands that it may be several months until pneumonia symptoms resolve. Once eligible, the patient should be educated on the benefits of the pneumococcal vaccine. (Norris, 2018; Pneumonia in Adults, 2019)
What cultural and age-related factors may have a bearing on the patient’s plan of care?
According to Cunha, risk factors for severe pneumonia increase with age due to pathologic changes in the immune system and lungs. Elderly patients have decreased mucociliary function and impaired B-lymphocyte function which leave them more susceptible to infections with encapsulated pathogens like streptococcus pneumoniae (2001). It is also important to assess Mr. Z’s attitude and belief system as it relates to implementing lifestyle changes like smoking cessation (Narayan, 2003).
2. What major outcomes do you expect to achieve for this patient?
Mr.Z clinical presentation indicates a systemic inflammatory response. The major outcomes that would be expected would be a return to stable vital signs, absence of fever and normalization of the arterial blood gas. The work of breathing will return to normal which should help the anxiety and agitation. The patient would return to baseline function and be able to perform activities of daily living without complications. Once respiratory status improves Mr.Z will be able tolerate food intake without any gastrointestinal complications.
What interventions must be initiated to monitor, prevent, manage, or eliminate the problems and risks identified?
The patients’ respiratory status must be addressed, the arterial blood gas indicates respiratory alkalosis from hyperventilation, but the PO2 is not critically low, concern would be due the increased work of breathing endotracheal intubation may be indicated although with the patients’ history of COPD being able to wean off the ventilator may be difficult as that 61% of those with COPD fail weaning from the ventilator (Kuo et al., 2016).Bipap may be used before proceeding with intubation, a small dose of sedation could also be tried to manage the patients anxiety and compliance with Bipap.
Fever management is also indicated to reduce the metabolic demand on the body to help improve oxygenation (Norris, 2019). Treatment for pneumococcal pneumonia is assumed to have been started that include antibiotics along with fluids as the indicated treatment for sepsis. The patients vital signs must be continuously monitored, would need to be transferred to the intensive care unit for continuous monitoring, vasopressors may be required if the patient mean arterial pressure drops below 65mmHg. Lastly due to the history of smoking a nicotine patch may also help some of the patients anxiety to prevent nicotine withdrawal.
What interventions should be initiated to promote optimal functioning, safety, and well-being of the patient?
Mr.Z is at risk for decline due to his mentation. A patient sitter may be indicated to keep him from removing his bipap mask. If a sitter is not effective, mittens may be used and escalate to wrist restraints if needed. Oral care must be completed, breaks from the bipap could be done for food and drink if tolerated, if not tolerated then Mr. Z could be assessed for total parental nutrition.
Toileting should be frequently monitored, a urinary catheter may be inserted if the Mr. Z is unable to use a urinal as a result of the shortness of breath.
What possible learning needs do you anticipate for this patient?
Smoking cessation will be required to address once Mr. Z mentation improves and is indicates willingness to learn. Smoking alters the normal flora within the tracheobronchial tree which places an individual at higher risk for infection (Norris, 2019).
The vaccination status of Mr. Z would need to be assessed and education on the importance of receiving the pneumococcal pneumonia vaccination due to the patient’s risk factors which include COPD and smoking.
What cultural and age-related factors may have a bearing on the patient’s plan of care?
Being a white male from the scenario, there might be some resistance with of lifestyle due to the era from which he grew up in. Age related factors included difficulty understanding how to administer medication especially inhalers properly (Sam, 2016). It is unknown if Mr.Z has family support which would be helpful for smoking cessation; could give him more motivation to make the lifestyle changes needed. Smoking was seen as a status for males and was prevalent in the higher socioeconomical groups which could hinder the desire for Mr. Z to quit (Di Novi & Marenzi, 2018).
3.This patient recently immigrated from Asia. As of 2018, South Asia holds almost 40% of the global Tuberculosis burden (Basnyat et al., 2018). Countries that have poorer access to healthcare generally have a higher prevalence of Tuberculosis. Those co infected with HIV and latent TB are at high risk for developing worsening disease. It’s important to recognize such cases and seek appropriate treatment (Basnyat et al., 2018).
A tuberculin skin test measures delayed hypersensitivity in response to exposure to tubercle bacillus. A positive reaction to the skin test does not indicate the person has active TB, they may have an inactive or dormant form known as latent TB. Those who once test positive to the tuberculin skin test usually remain positive for the remainder of their life. A positive skin test indicates there has been exposure to the bacillus at some point and cell-mediated immunity to the organism has developed but does not specifically pinpoint the time this occurred (Norris, 2019). In this case, this patient states she has latent TB.
The QuantiFERON-tb gold test is used to detect both active and latent TB by measuring interferon-y which is also part of the cell mediated immune activity for TB response. It has a 24-hour test result turnaround time but is expensive and not easily available.
However, QuantiFERON-tb gold test also cannot distinguish between active or latent form of tuberculosis (Ryu, 2015). Definitive diagnosis of active TB requires identification of the organism for cultures or from DNA or RNA amplification techniques. Bacteriologic studies of early sputum specimens, gastric aspirations, or bronchial washing may also be used for diagnostic purposes (Norris, 2019).
The general treatment goal is to eliminate all tubercle bacilli from the infected person. Treatment of active TB requires the use of multiple drugs due to the increase of drug resistance (Ryu, 2015). People with active TB and people who have had contact with cases of active TB and at risk for development of an active form of the disease meet the criteria for the use of antimycobacterial therapy for TB.
Prophylactic treatment is used for those infected with M. tuberculosis but do not have active disease (Norris, 2019). In this case, it would be important to find out if this patient has had any recent contact with cases of TB, if her TB was properly treated initially, results of chest XRAY and bacteriologic studies, and the status of her immune state. The appropriate therapy would be indicated based upon such results and to keep her latent TB in the inactive state and prevent it from becoming active again (Ryu, 2015).
The Mantoux tuberculin skin test is the only skin test to identify tuberculosis. There are however other diagnostic tools such as chest x-ray, QuantiFERON-gold TB test, and sputum cultures.
4.COLLAPSE
Tuberculosis (TB) described by Norris, as an infectious disease caused by mycobacterium, M tuberculosis. TB is seen more commonly in foreign born individuals in countries known to have a high incidence rate of the infectious disease and in areas where there are more establishments of homelessness, treatment/rehab facilities, and correctional centers (Norris, 2019).
TB is known as respiratory illness most commonly affecting the lungs. However, TB affects multibody systems stemming from the pulmonary manifestations but includes but are not limited to gastrointestinal, lymphatic, central nervous system, musculoskeletal, reproductive, integumentary systems, and liver (Adigun & Singh, 2021).
Tuberculosis, which is also referred to as fast acting bacilli (AFB), is a non-spore forming aerobic rod shaped like bacteria. Due to its waxy outer layer, makes it more difficult to treat. Tubercle bacilli thrives in environments rich in oxygen (Norris, 2019). Hence, TB commonly referred to known as a pulmonary respiratory airborne condition most often present in the lobes of the lungs.
Testing for TB is completed using a tuberculin skin and or x-ray. The skin test measures delayed hypersensitivity to the exposure of tubercle bacillus causing a raised bump on the skin typically measuring greater than 10mm. Other tests to confirm TB may include cultures and testing for AFB sputum sensitivity, gastric aspirations, or bronchial washings (Norris, 2019).
Once a person tests positive for TB, they will remain positive throughout their lifetime. However, a reaction to the tuberculin test does not necessarily confirm active TB, but confirm exposure to TB (Norris, 2019). Typically, is a patient test and are confirmed positive for TB they are no longer a latent stage. Latent TB is when tubercle bacilli is present but not in an active or contagious stage (Ilievska-Poposka, B, Metodieva, M., Zakoska, M., Vragoterova, C., & Trajkov., 2018).
The most common treatment methods for TB are by medications. The goal of treatment is to irradiate or eliminate all tubercle bacilli yet being careful to prevent drug resistance. A combination of medications has known to be most effective. Medications used to treat TB are INH, rifampin, pyrazinamide (PZA), ethambutol, and streptomycin Norris, 2019).
People of color which includes individuals of Asian ethnicities are subjected to psychological and treatment disparities. Asians are very stoic civilians and seeking help, assistance, medical advice, and consult may not be a situation that the patient may be accustomed to.
In addition, other considerations are English as a second language and Western medicine in comparison to her previous practice history. Exercising cultural competence to learn Asian treatment methods and rituals are essential to respecting the patient’s culture and individuality. She has also felt more comfortable with a female clinician
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