Scott’s Tots

Pneumonia

Victoria, Nashaly, Meagan, Jason, Cassi

Case Synopsis
Chief complaint: Patient presented to the ED with shortness of breath, cough and fever for four days

History: 35 year old man who developed a harsh, productive cough four days prior to being seen
by a physician.

● The sputum is thick and yellow

● He developed a fever, shaking, chills and malaise along with the cough
● One day ago he developed pain in his right chest that intensifies with inspiration
● Past history reveals that he had a chronic smoker's cough for "10 or 15 years" which he
describes as being mild, non-productive and occurring most often in the early morning
● He smoked 2 packs of cigarettes per day for the past 50 years
Case Synopsis
Physical examination:
● Patient is underweight
● Continuous cough
● Sitting in a chair, he leans to his right side, holding his right chest with his left arm.
● Vital signs: blood pressure 152/90, apical heart rate 112/minute and regular, respiratory rate 24/minute and
somewhat labored, temperature 102.6 F
● Auscultation reveals bilateral rhonchi and late inspiratory crackles (are heard)
● Clubbing of fingers

LABORATORY:
● WBC 17,000/mm3; neutrophils 70%, bands 15%, lymphocytes 15%.

COURSE OF ILLNESS:
● Chest x-ray revealed an acute pneumonia in the right middle lobe, the patient was treated with antibiotics
➔ Assessment
◆ shortness of breath, cough and
fever, yellow sputum, abnormal
breathing patterns, restlessness,
clubbing of fingernails
➔ Nursing Diagnosis
◆ Impaired gas exchange r/t to
pneumonia as evidenced by
abnormal breathing patterns and
clubbing of fingernails
➔ Planning
◆ Client will demonstrate improved
ventilation and adequate
oxygenation as evidenced by
blood gas levels within normal
parameters
◆ Maintain clear lung fields and
remain free of signs of respiratory
distress
Nursing Process ➔ Implementation
◆ Monitor rr, depth, and ease of
respiration. Watch for use of
accessory muscles and nasal
flaring
◆ Auscultate breath sounds
every 1 to 2 hours. The
presence of crackles and
wheezes may alert the nurse
of airway obstruction, which
may lead to or exacerbate
existing hypoxia.
◆ Help the client deep breathe
and perform controlled
coughing.
➔ Evaluation
◆ O2 sat is above 93%
◆ Clear lung sounds upon
auscultation
◆ Fingernails no longer clubbing
(Ackley, 2017).
Therapy for Pneumonia
● Ensure that the patient is receiving adequate oxygen
○ Are they cyanotic?
○ Is there suction nearby to clear their airway?

● Treat with empirical antibiotics

○ Broad spectrum
○ Gram positive
○ What happens if the strain is resistant?

● Encourage the patient to use nonpharmacologic techniques

as well!
○ Coughing
○ Deep breathing
○ Keep the patient well hydrated
(McKance, K. L., 2014)
 (Parnham, et al., 2014)
(Loeb, 2008)

Medication used
Zithromax (Azithromycin)
● Drug Class: Macrolide Antibacterial Antibiotic
● Azithromycin is indicated for respiratory, urogenital, dermal and other
bacterial infections, and exerts immunomodulatory effects in chronic
inflammatory disorders
● Long-term administration of azithromycin must be balanced against
the potential for increased bacterial resistance.
● Treatment with azithromycin achieved a success rate (cure plus
improvement) of 78% for the treatment of community-acquired
pneumonia in a clinical study
 (Micromedex, 2018)

Route: Intravenous, ophthalmic and oral

Onset of Action: Azithromycin is rapidly absorbed after oral

administration. Food does not interfere with absorption of
tablet or suspension of azithromycin but of capsule is reduced.

Peak plasma concentration: Occurs 2 to 3 hours after an oral

dose and 1 to 2 hours after intravenous dosage.

Elimination Half-life: An average terminal half-life of a single

dose is 11 to 14 hours and 68 hours with multiple.

Duration of Action: Up to 24 hours

Duration of treatment
● The patient began treatment
once the CXR confirmed the
pneumonia diagnosis
● While in the hospital, they will
receive 500 mg of IV Zithromax
daily while in the hospital
● Just prior to discharge, give
ONE dose of 500 mg oral
Zithromax
● Discharge with a 4 day course of
250 mg oral Zithromax

(Ackley, 2017)
 (Vallerand, 2019).

Drug action
● Inhibit protein synthesis at the level
of the 50S bacterial ribosome
● Know effectiveness by monitoring
vital signs, CBC - specifically WBC
Tip
count, and bacteria growth from
Be cautious - may
temporarily sputum samples
increase other ● First dose can be given before
values, such as receiving results of sputum bacteria
PPT, BUN, and
serum creatinine growth
MAR
Order Therapeutic Follow-up
Azithromycin extended action Monitor patient’s O2 saturation
release formula: 2g PO to ensure effective oxygen
Reduction in the number perfusion.
one time only
of microorganisms
causing the pneumonia. Monitor lung sounds for a
("Azithromycin Dosage reduction in crackles/ronchi.
Guide with Precautions",
2018) (Ackley,2017) (Ackley, 2017)
Special considerations
Side effects of azithromycin include: Diarrhea, nausea,
abdominal pain, loose stools, and flatulence.

Pregnancy category: B

Can be administered orally or in injectable form.

Taking the drug with food reduces both the rate and
extent of GI absorption.

(Ackley, 2017)
References
Ackley, B., & Ladwig, G. (2016). Nursing diagnosis handbook: An evidence-based guide
to planning care (11th ed.). St. Louis: Mosby/Elsevier.

Lilley, L.L., Collins, S.R, & Snyder, J.S. (2016). Pharmacology and the nursing process,
8th Ed. St. Louis: Elsevier Mosby.

Azithromycin Dosage Guide with Precautions. (2018, October 31). Retrieved from
https://www.drugs.com/dosage/azithromycin.html#Usual_Adult_Dose_for_Pneumonia

Loeb, M. (2008). Community-acquired pneumonia. BMJ Clinical Evidence, 2008(1503).

Retrieved November 7, 2018, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907969/.

McCance, K. L., & Huether, S. E. (2014). Pathophysiology: The biologic basis for disease
in adults and children. St. Louis, MO: Mosby.

Nuermberger, Eric L.,, Bishai, William R. Antibiotic Resistance in Streptococcus

pneumoniae: What Does the Future Hold?, Clinical Infectious Diseases, Volume 38, Issue
Supplement_4, 15 May 2004, Pages S363–S371, https://doi.org/10.1086/382696

Vallerand, April Hazard, et al. Davis's Drug Guide for Nurses. F.A. Davis Company,
2019.

Parnham, M. J., Haber, V. E., Giamarellos-Bourboulis, E. J., Perletti, G., Verleden, G. M.,
& Vos, R. (2014). Azithromycin: Mechanisms of action and their relevance for clinical
applications. Pharmacology & Therapeutics, 143(2), 225-245.
doi:10.1016/j.pharmthera.2014.03.003