cLiNic fReaK

This is from http://wikipedia.org.

Community-acquired pneumonia (CAP) is a disease in which individuals who have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect people of all ages. CAP often causes problems breathing, fever, chest pains, and a cough. CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively.

CAP occurs throughout the world and is a leading cause of illness and death. Causes of CAP include bacteria, viruses, fungi, and parasites. CAP can be diagnosed by symptoms and physical examination alone, though x-rays, examination of the sputum, and other tests are often used. Individuals with CAP sometimes require treatment in a hospital. CAP is primarily treated with antibiotic medication. Some forms of CAP can be prevented by vaccination.

Symptoms of CAP commonly include:

• problems breathing
• coughing that produces greenish or yellow sputum
• a high fever that may be accompanied with sweating, chills, and uncontrollable shaking
• sharp or stabbing chest pain
• rapid, shallow breathing that is often painful

Less common symptoms include:

• the coughing up of blood (hemoptysis)
• headaches (including migraine headaches)
• loss of appetite
• excessive fatigue
• blueness of the skin (cyanosis)
• nausea
• vomiting
• diarrhea
• joint pain (arthralgia)
• muscle aches (myalgia)

The manifestations of pneumonia, like those for many conditions, might not be typical in older people. They might instead experience:

• new or worsening confusion
• hypothermia
• falls

Additional symptoms for infants could include:

• being overly sleepy
• yellowing of the skin (jaundice)
• difficulties feeding

The symptoms of CAP are the result of both the invasion of the lungs by microorganisms and the immune system’s response to the infection. The mechanisms of infection are quite different for viruses and the other microorganisms.

• Viruses

Viruses must invade cells in order to reproduce. Typically, a virus will reach the lungs by traveling in droplets through the mouth and nose with inhalation. There, the virus invades the cells lining the airways and the alveoli. This invasion often leads cell death either through direct killing by the virus or by self-destruction through apoptosis. Further damage to the lungs occurs when the immune system responds to the infection. White blood cells, in particular lymphocytes, are responsible for activating a variety of chemicals (cytokines) which cause leaking of fluid into the alveoli. The combination of cellular destruction and fluid-filled alveoli interrupts the transportation of oxygen into the bloodstream. In addition to the effects on the lungs, many viruses affect other organs and can lead to illness affecting many different bodily functions. Viruses also make the body more susceptible to bacterial infection; for this reason, bacterial pneumonia often complicates viral CAP.

• Bacteria and fungi

Bacteria and fungi also typically enter the lung with inhalation, though they can reach the lung through the bloodstream if other parts of the body are infected. Often, bacteria live in parts of the upper respiratory tract and are constantly being inhaled into the alveoli. Once inside the alveoli, bacteria and fungi travel into the spaces between the cells and also between adjacent alveoli through connecting pores. This invasion triggers the immune system to respond by sending white blood cells responsible for attacking microorganisms (neutrophils) to the lungs. The neutrophils engulf and kill the offending organisms but also release cytokines which result in a general activation of the immune system. This results in the fever, chills, and fatigue common in CAP. The neutrophils, bacteria, and fluid leaked from surrounding blood vessels fill the alveoli and result in impaired oxygen transportation. Bacteria often travel from the lung into the blood stream and can result in serious illness such as septic shock, in which there is low blood pressure leading to damage in multiple parts of the body including the brain, kidney, and heart.

• Parasites

There are a variety of parasites which can affect the lungs. In general, these parasites enter the body through the skin or by being swallowed. Once inside the body, these parasites travel to the lungs, most often through the blood. There, a similar combination of cellular destruction and immune response causes disruption of oxygen transportation.

Treatment

CAP is treated by administering an antibiotic which is effective in killing the offending microorganism as well as managing any complications of the infection. If the causative microorganism is identified, different antibiotics are tested in the laboratory in order to identify which medication will be most effective. Often, however, no microorganism is ever identified. Also, since laboratory testing can take several days, there is some delay until an organism is identified. In both cases, a person’s risk factors for different organisms must be remembered when choosing the initial antibiotics (called empiric therapy). Additional consideration must be given to the setting in which the individual will be treated. Most people will be fully treated after taking oral pills while other people need to be hospitalized for intravenous antibiotics and, possibly, intensive care. In general, all therapies in older children and adults will include treatment for atypical bacteria. Typically this is a macrolide antibiotic such as azithromycin or clarithromycin although a fluoroquinolone such as levofloxacin can substitute.

Prognosis

Individuals who are treated for CAP outside of the hospital have a mortality rate less than 1%. Fever typically responds in the first two days of therapy and other symptoms resolve in the first week. The x-ray, however, may remain abnormal for at least a month, even when CAP has been successfully treated. Among individuals who require hospitalization, the mortality rate averages 12% overall, but is as much as 40% in people who have bloodstream infections or require intensive care. Factors which increase mortality are the same as those which increase the need for hospitalization and are listed above.

When CAP does not respond as expected, there are several possible causes. A complication of CAP may have occurred or a previously unknown health problem may be playing a role. Both situations are covered in more detail below. Additional causes include inappropriate antibiotics for the causative organism (ie DRSP), a previously unsuspected microorganism (such as tuberculosis), or a condition which mimics CAP (such as Wegener’s granulomatosis). Additional testing may be performed and may include additional radiologic imaging (such as a computed tomography scan) or a procedure such as a bronchoscopy or lung biopsy.

Prevention

In addition to treating any underlying illness which can increase a person’s risk for CAP, there are several additional ways to prevent CAP. Smoking cessation is important not only for treatment of any underlying lung disease, but also because cigarette smoke interferes with many of the body’s natural defenses against CAP.

Vaccination is important in both children and adults. Vaccinations against Haemophilus influenzae and Streptococcus pneumoniae in the first year of life have greatly reduced their role in CAP in children. A vaccine against Streptococcus pneumoniae is also available for adults and is currently recommended for all healthy individuals older than 65 and any adults with emphysema, congestive heart failure, diabetes mellitus, cirrhosis of the liver, alcoholism, cerebrospinal fluid leaks, or who do not have a spleen. A repeat vaccination may also be required after five or ten years.

Influenza vaccines should be given yearly to the same individuals as receive vaccination against Streptococcus pneumoniae. In addition, health care workers, nursing home residents, and pregnant women should receive the vaccine. When an influenza outbreak is occurring, medications such as amantadine, rimantadine, zanamivir, and oseltamivir have been shown to prevent cases of influenza.

At the moment I arrived at my patient’s bedside, I uttered my usual introduction, “Good evening po. I am Glen Belle Baslao, student nurse from University of Mindanao. Pwede nyo po akong tawaging Glen.” Since it was time for Vital Signs taking, I then gathered my paraphernalia for VS (one medicine glass, cotton balls soaked in alcohol, axillary thermometer, shygmomanometer, and stethoscope). I started with wiping out the thermometer with a cotton ball, placed it on the patient’s axilla. Then, with my watch, I checked the Pulse rate, next the Respiratory rate. After taking the PR and RR, I retrieved the thermometer, and read the temperature, “Ah, 36.4ºC”, wiped the thermometer with another cotton ball and replaced it into the container. Then I checked the patient’s Blood Pressure..90/70mmHg.. After recording the data on the patient’s VS, I started asking for whatever he felt during the day, if there were any improvements in his breathing (since he has been diagnosed to have a certain type of Pneumonia), or if he has any other complaints at all. His watchers told me that their grand dad has not yet taken in anything except for a little water, and has refused to eat at all. As their student nurse, I can see in their eyes that they really are worried about the patient. I can sense their anxiety towards the illness of their loved one.

After I gave some health teachings, I arranged the patient’s bed and was quite glad I did it really well. I then regulated the IVF of PNSS to 30gtts/min, went out of the ward, relaxed. Time’s ran real fast, I didn’t even noticed that it was already past 1:00am. My groupmates were asking me if I would like to join them for a 30-minute break/snacks. I refused since I still feel quite full because of Tita Hilda’s very yummy dinner she has prepared. All I did between 1:00am to 2:00am is chat with some of my groupmates. I went back to my patient’s ward, checking out the IVF if it is infusing well. I was glad I did rechecked it. Why? Because when I got there, I saw my patient’s arm being wrapped with the IV tubes already, and what a great problem it would make if the cannula will be dislodged in the patient’s metacarpal vein. That would mean a risk for swelling and resiting for a new IV line and more pain. So, I arranged the tubes neatly and positioned the arm in place, informing the watcher to keep watch with the tube to as to prevent injury.

We took our break at 3:00am. At 3:30am, we headed back to the MedCP and rechecked the vital signs. In a little more while, we saw the sun rise up that signaled the nearing end of our shift. I felt glad. At last, I can rest.

When I had my first graveyard shift duty last Tuesday, I was dumbfounded with the way the Nurse on Duty is reacting towards the patients admitted in the Medicine Ward. For the background, the Medicine Ward-MED CP, is one of the most “toxic” wards in the Davao Medical Hospital. In the Med-ward area, there are more or less 60 patients admitted in there, mostly suffering from communicable diseases such as Pulmonary Tubercolosis, Community Acquired Pneumonia, Hepatitis B, Hepatic diseases, and the like. Since most of the patients admitted there are with problems with ABC (Airway, Breathing, and Circulation), many of them die everyday. This ward is known to be of “high mortality” rate than that of the other wards in the hospital.

After we oriented with the nurse station, we were given the endorsements for the patients that we will be handling. I remembered the NOD saying like this, “Endorsing patient ___, to be transferred in the ICU room..but as you can see, it is really full of patients at the moment, so hindi pa naitatransfer. Pwera nalang kung may mamamatay tonight. Kung may mamatay, itranfer agad si __ dun.”. I was shocked upon hearing it from the NOD. I wonder if the nurses there have time to go to San Diego bars and get themselves a life. Anyway, Yeah, death is just a part of the cycle of life. When you live, you die. It’s the end of everything, period. It is already perceived and expected, I know, but, it doesn’t mean that when there is a very high incidence of death, you’ll really be hoping for it–as if you do not care about those people who will die (and their loved ones) at all. Ideally, a nurse should be armored with care and with compassion, giving its best to every patient it deals with. If one patient dies, he will die peacefully..at least, nobody hoped for his death.

Being numb about suffering and about death is something that I am afraid of. I don’t want to see myself being so used with suffering and death someday. Loosing the feeling of dread and of loneliness would mean I also have lost the essence of being alive, of being human. Numbness is congruent to not living..or even death itself.