Main discussion – Week 9
Case Study 1
HH is a 68 yo M who has been admitted to the medical ward with community-acquired pneumonia for the past 3 days. His PMH is significant for COPD, HTN, hyperlipidemia, and diabetes. He remains on empiric antibiotics, which include ceftriaxone 1 g IV qday (day 3) and azithromycin 500 mg IV qday (day 3). Since admission, his clinical status has improved, with decreased oxygen requirements. He is not tolerating a diet at this time with complaints of nausea and vomiting.
Ht: 5’8” Wt: 89 kg
Allergies: Penicillin (rash)
Nutrition status. The patient is not tolerating diet, related to nausea (N) and vomiting (V). It is unclear in the case scenario when the patient first complained of N and V. It is less likely to be caused by CAP (Baer, 2019). It can be a side effect of the antibiotics (Rxlist, 2018), or related to a condition undiscovered by the provider yet. Further physical examination and a KUB are necessary to determine if the N and V are a side effect of the medications or caused by a different condition.
Hydration status of the patient. The patient has been having N and V. It is essential to maintain the patient well hydrated during recovery time because hydration loosens up the secretion, which makes it easier for the patient to breathe by coughing and clearing up their airway (Ausmed, 2017). Strict intake and output measurement are essential to prevent dehydration.
Length of IV antibiotic therapy. The Infectious Diseases Society of America (IDSA) recommends treating CAP patients who are hospitalized with five to seven days of empiric antibiotics (File, 2020). IDSA recommends to re-evaluate patients by the fifth to the seventh day before stopping the antibiotic, extend the therapy needed if the patient is febrile, needs supplemental oxygen (unless required for a preexisted condition), and patient clinically unstable (HR>100, RR>24, and SBP<90) (File, 2020).
Metoclopramide 10 mg IV Q6H to control the N and V if no underlining condition was found (Entringer, 2019).
If the patient is unable to drink, start the patient on IV fluid replacement therapy with normal saline 0.9 at 75 ml/hr.
Total fluid volume per day [weight (kg) x 20 ml/kg/day] = 89 x 20= 1780 ml
Infusion rate = total fluid volume per day ÷ 24 hour = 1780 ÷ 24= 74.1= 75 ml/hr (EBM Consult, n.d.).
I would recommend continuing the patient’s current antibiotic until day 7. Then, re-evaluate the patient before stopping them. I do not feel the need to change the current antibiotic because the patient’s status is improving, and he requires less O2.
Reconcile the patient’s home medications except for the diabetes medications. The most important medication to reconcile is the COPD medication, to prevent COPD exacerbation, which can lead to an increase risk of mortality (Braeken et al., 2014).
Sliding-Scale Insulin (SSI) to treat the patient’s high blood sugar. Studies show SSI has better ability to keep patients’ blood sugar within or close to target during hospitalization by administrating short-acting insulin frequently (Ambrus & O’Connor, 2019)
Encourage the patient using incentive spirometer (IS). IS can help him practice taking deep breaths, which can help open the airways, prevent fluid or mucus from building up in the lungs, make it easier for the patient to breathe, and lower the O2 supplement demand (Healthwise, n.d.).
Take Metoclopramide before a meal to prevent N and V and to improve the nutrition status, and hydration status.
Teach the patient how to use IS and the benefit of using IS.
The patient is above the age of 65 years old and has COPD, which increases the risk of CAP. Educate the patient about getting the pneumonia vaccine before discharge to lower the risk of recurrent pneumonia in the future (Centers for Disease Control and Prevention, 2019).
Ambrus, D. B., & O’Connor, M. J. (2019). Things We Do For No Reason: Sliding-Scale Insulin as Monotherapy for Glycemic Control in Hospitalized Patients. Journal of Hospital Medicine, 14(2), 114-116. doi:10.12788/jhm.3109
Ausmed. (2017). Pneumonia Symptoms, Signs and Treatment. Retrieved July 26, 2020, from https://www.ausmed.com/cpd/articles/pneumonia-explained
Baer, S. L. (2019). Community-Acquired Pneumonia in Adults. Retrieved July 26, 2020, from https://www.cedars-sinai.org/health-library/diseases-and-conditions/c/community-acquired-pneumonia-in-adults.html
Braeken, D., Franssen, F., Schütte, H., Pletz, M., Bals, R., Martus, P., & Rohde, G. (2014). Increased Severity and Mortality of CAP in COPD: Results from the German Competence Network, CAPNETZ. Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation, 2(2), 131-140. doi:10.15326/jcopdf.2.2.2014.0149
Centers for Disease Control and Prevention. (2019, November 21). Pneumonia Can Be Prevented-Vaccines Can Help. Retrieved July 26, 2020, from https://www.cdc.gov/pneumonia/prevention.html
Entringer, S. (2019). Reglan Uses, Dosage & Side Effects. Retrieved July 26, 2020, from https://www.drugs.com/reglan.html
EBM Consult. (n.d.). Maintenance Fluid Calculator. Retrieved July 26, 2020, from https://www.ebmconsult.com/app/medical-calculators/maintenance-fluid-calculator?change_to_si=NO
File, T. M. (2020). Treatment of community-acquired pneumonia in adults who require hospitalization. Retrieved July 26, 2020, from https://www.uptodate.com/contents/treatment-of-community-acquired-pneumonia-in-adults-who-require-hospitalization
Healthwise. (n.d.). Breathing Exercises: Using a Manual Incentive Spirometer. Retrieved July 26, 2020, from https://www.healthlinkbc.ca/health-topics/abj5949
Rxlist. (2018, December 21). Side Effects of Ceftriaxone (Ceftriaxone Sodium and Dextrose Injection ), Warnings, Uses. Retrieved July 26, 2020, from https://www.rxlist.com/ceftriaxone-side-effects-drug-center.htm