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Unit V Promoting Health in Patients With Oxygenation Disorders
4. Heart rate greater than 125 beats per minute 5. Body temperature less than 95°F (35°C) or greater than 104°F (40°C) 6. Arterial blood pH less than 7.35 7. Serum sodium level less than 130 mg/dL 8. Hematocrit less than 30% 9. PaO 2 less than 60 mm Hg on supplemental oxygen greater than or equal to 40% 10. Presence of pleural effusion on chest x-ray or com- puted tomography (CT) scan
hospitalization and supportive care. Because pneumonia may result in hypoxia, administration of oxygen to reverse or prevent hypoxia is an essential first step. In the case of patients with chronic lung pathology, high concentrations of oxygen can depress the drive to breathe. Those patients require careful monitoring while receiving oxygen. Ensur- ing adequate hydration is also an important intervention to support the patient’s cardiovascular status and assist in thinning respiratory secretions for easy expectoration. Medications Bronchodilator therapy with albuterol (short-acting selec- tive beta-2 adrenoceptor agonist) or Combivent (slow- onset anticholinergic agent) delivered either by aerosol nebulization or by metered-dose inhaler will open swollen and narrowed airways and promote ease of breathing. Antibiotic therapy, the definitive treatment, is based on the offending organism, and initially, broad-spectrum anti- biotics are initiated promptly. For HAP, antibiotic treat- ment is empirical—treatment based on clinical experience before the exact offending organism is identified. Because Pseudomonas aeruginosa is the major pathogen associated with HAP, initial treatment is focused on that organism. Specific antibiotic recommendations for the treatment of CAP, HCAP, and HAP are outlined in Table 24.9. Complications Severe MRSA CAP can lead to a necrotizing bacterial pneu- monia requiring hospitalization. In aspiration pneumonia, the acidity of stomach contents is caustic to the delicate lung tissue. A necrotizing pneumonia may develop, resulting in fibrosis and scarring of the lung tissue. Pulmonary fibro- sis and pulmonary hypertension from severe pulmonary infections can impair lung function after the respiratory
Interprofessional Management Medical Management Diagnosis
Diagnosis is based on laboratory and imaging studies. Lab- oratory findings consistent with the diagnosis of pneumonia include the following: l Elevated WBC count (leukocytosis) with elevated bands (immature neutrophils) on differential indicating acute inflammation l Elevated C-reactive protein level, an accurate, sensi- tive, and historically used test to detect the presence of inflammation and infection. Values can range from 30 to 300 mg/dL in cases of bacterial and viral pneumonia. l Arterial blood gases may initially reflect a primary respiratory alkalosis (decreased CO 2 , increased pH) due to tachypnea. As the condition progresses, a primary respiratory acidosis with hypoxemia (elevated CO 2 , decreased PaO 2 , and decreased pH) will occur. l Sputum cultures will reveal a preliminary category of the offending organism by Gram stain and confirm the specific organism after 24 to 48 hours of incuba- tion in the laboratory. Expectorated sputum specimens yield little information because of contamination with normal oral bacteria. Specimens obtained by deep tracheal suctioning or bronchoscopy offer the best yield for confirming a diagnosis and directing the choice of antimicrobial management. Imaging studies reveal the following: l Chest x-rays may or may not show infiltrates and can be up to 72 hours behind in their ability to reveal an infectious process. l Computed tomography scans of the chest may better demonstrate consolidation (solidification of lung tissue) and the presence of pleural effusions. As noted previously with clinical manifestations, prompt diagnosis is essential in providing timely and effective treatment. Treatment The treatment of pneumonia is dependent on the type of pneumonia, an early diagnosis, and the overall health of the patient. Uncomplicated pneumonias can be effectively treated in the outpatient setting. More severe cases require
Table 24.9 Recommended Antimicrobial Treatment for Community-Acquired Pneumonia
Recommended Antimicrobials
Patient Assessment
Outpatients Previously healthy l No antibiotics within the past 3 months
Macrolides or doxycycline
l Comorbidities
Respiratory fluoroquinolones OR β -Lactam antibiotics and a macrolide Respiratory fluoroquinolones OR β -Lactam and a macrolide If MRSA CAP: add vancomycin or linezolid
l Have received antibiotics within the past 3 months
Inpatients (all)
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