Mr. Edward Hunter, an 89-year old widower, was admitted to your medical ward with hypoxaemia (oxygen saturations 82% in the ambulance) and a recent history of viral influenza. He has been receiving...

Mr. Edward Hunter, an 89-year old widower, was admitted to your medical ward with hypoxaemia (oxygen saturations 82% in the ambulance) and a recent history of viral influenza. He has been receiving intensive home support from the ‘acute care in the home’ nursing team for over 6 months, which includes home oxygen therapy. One month ago, he suffered a myocardial infarction, which was preceded by frequent episodes of unstable angina. He had a coronary stent inserted in 2007. Within 24 hours of admission Mr. Hunter’s condition continues to deteriorate. He is receiving 15 litres of oxygen via the non-rebreather mask. Severe dyspnoea renders him immobile and barely able to eat. He has little appetite and is cachexic. Overnight night he becomes quite restless and distressed by his pain, breathlessness, tachypnoea and cough. The palliative care team reviewed Mr. Hunter because he was experiencing increased pleuritic pain on inspiration and was expectorating rust colored sputum. Subsequently, he was diagnosed with pneumococcal pneumonia and was prescribed morphine 5mg (5mg/ml) solution nocté for the analgesic, cough suppressant, a sedative and antibiotics. Consider the patient situation Question 1. Mr Hunter is 89 years old. What are the specific considerations a Registered Nurse should understand in relation to the clinical manifestations of pneumonia in the older person? Collect information: pathophysiology Question 2. Outline the pathophysiology of altered ventilation and diffusion in relation to Mr Hunter’s pneumonia. Your answer should include pathological response in cells and tissues. Yesterday evening, in handover to the night duty nurse, it was explained that the palliative care team had reviewed Mr. Hunter again and reduced the dose of morphine to 2-0 – 2.5mg nocté because he was becoming confused and drowsy during the day but was easily roused and orientated once woken and maintaining oxygen saturations 92 -94%. Mr. Hunter is clearly distressed and extremely dyspnoeic. The consultant arrives to review Mr. Hunter and prescribes endone suppository 30mg rectally PRN and oxycontin 10mg orally 12 hourly PRN. Mr Hunter’s current prescribed medications include: Nicorandil (Ikorel) 10mg PO BD Aspirin 75mg PO daily marne Ramipril 5mg PO BD Paracetemol (Panadol) 1 – 2 tablets PO PRN (Maximum 4gm/day) Simvastatin PO 20mg nocte Morphine 2.0 – 2.5 mg PO PRN Noctéé4-6 hourly Docusate (Coloxyl tablets) 1 tablet BD Metoclopromide (Maxalon) 10mg PO PRN TDS Oxygen (high flow) to achieve oxygen saturation > 92% The consultant reviews Mr. Hunters medication and prescribes Benzyl penicillin 1.2 IV 6 hourly for a total of 7 days Process information Interpreting information can be difficult if you process it subjectively based on your own past experiences, beliefs and opinions. By critically appraising the information about the various types of pneumonia, it is possible to make a reasoned judgment about Mr. Hunter’s future management. Question 3. What are the differences between hospital acquired pneumonia (HAP, community acquired pneumonia (CAP)and aspiration pneumonia? Your answer should include causative organisms. Part 2. The consultant arrives to review Mr. Hunter and prescribes endone (30mg) rectal suppository PRN and oxycontin 10mg orally 12 hourly PRN. As directed by the consultant, the consultant also requests that Mr. Hunter has 4 hourly observations of his vital signs and to report a heart rate above 100 and oxygen saturations below 90% and a temperature above 38.5c. Take action The registered nurse recognises that Mr. Hunter requires care beyond that requested by the consultant. Question 4. Explain the nursing care required the patient with pneumonia. Provide a rationale for all elements of the care provided that reflects the particular needs of Mr. Hunter. Make reasoned judgments Question 5. The consultant has asked to be informed if Mr. Hunters heart rate rises above 100, oxygen saturations fall below 90% and his temperature rises above 38.5c. In the context of a patient with pneumonia, explain the rational/s for monitoring the specific parameters requested by the consultant. The central principles of social justice are Self Determination, Equity, Access, Rights and Participation. One morning you notice Mr Hunter agitated and his oxygen mask is on the floor. He requests that his oxygen be stopped as he doesn’t like it as it is causing him discomfort. The RN recognises that he has a right to control his own treatment, however understands the impact this will have on his health. Question 6. Explain (1) the strategies you would use to ensure Mr. Hunter understands the implications of his decisions and (2) the actions you would take to manage the situation.