Med Surg Case Study #33: Francis Jordan

Med Surg Case Study #33: Francis Jordan

Francis Jordan |  75 years old

Chief Complaint: Francis Jordan presents with difficulty breathing and a persistent cough that started after a choking incident during a meal.

Medical History:

• History of gastroesophageal reflux disease (GERD)

• Previous stroke with residual dysphagia

• Hypertension

• Type 2 Diabetes Mellitus

• Chronic kidney disease stage 3

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0845

Nurse's Note: Patient reports shortness of breath, cough with yellowish sputum, and chest pain on inspiration. Patient has a fever and appears anxious and uncomfortable. Noted slight cyanosis around the lips.

Vital Signs:

• Blood pressure: 160/92 mmHg

• Heart rate: 105 bpm

• Respiratory rate: 24 breaths/min

• Temperature: 101.2°F (38.4°C)

• SpO2: 89% on room air

Provider's Orders:

• Administer oxygen via nasal cannula at 2 L/min.

• Obtain a chest X-ray and CT scan.

• Order a sputum culture and blood tests, including CBC and arterial blood gases (ABG).

• Start empirical antibiotic therapy with ceftriaxone 1g IV and metronidazole 500mg IV, after sputum sample is collected.

• Keep the patient NPO (nil per os) until swallowing assessment is completed.
  

1215

Nurse's Note: Oxygen therapy initiated; O2 saturation improved to 93%.

Chest X-ray and CT scan show infiltrates in the right lower lobe. Sputum culture sent to the lab; awaiting results. Patient appears less anxious but still reports chest pain and cough.

Vital Signs

• Blood pressure: 158/90 mmHg

• Heart rate: 98 bpm

• Respiratory rate: 22 breaths/min

• Temperature: 100.8°F (38.2°C)

• SpO2: 93% on 2 L/min nasal cannula

Provider's Orders:

• Administer acetaminophen 650 mg PO for fever and pain.

• Consult speech therapy for a swallowing assessment.

• Begin IV fluids with normal saline at 75 mL/hr.

1800

Echocardiogram preliminary results indicate mitral valve prolapse with mild mitral regurgitation.

Nurses Note:

• Speech therapy assessed the patient; recommended thickened liquids and pureed foods.

• Patient tolerating oxygen therapy well; reports slight improvement in breathing.

• Sputum culture pending; blood tests show elevated WBC count.

• Patient's family educated on aspiration precautions and diet modifications.

Vital Signs:

• Blood pressure: 156/88 mmHg

• Heart rate: 96 bpm

• Respiratory rate: 20 breaths/min

• Temperature: 100.2°F (37.9°C)

• SpO2: 94% on 2 L/min nasal cannula
  

Provider's Orders:

• Maintain upright position during and after meals.

• Schedule a follow-up chest X-ray in 48 hours.

• Reassess swallowing function in 24 hours.

Follow Up Questions:

Question 1: What factors contributed to Francis's aspiration pneumonia?

Question 2: Why was oxygen therapy initiated for Francis?

Question 3: What is the importance of obtaining a sputum culture in the management of aspiration pneumonia?

Question 4: Why is it essential to keep Francis NPO initially and then adjust her diet to thickened liquids and pureed foods?

Answers to Questions Below

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Answers

Question 1: What factors contributed to Francis's aspiration pneumonia?

Francis's aspiration pneumonia likely resulted from her dysphagia due to a previous stroke and GERD. Dysphagia and GERD are common risk factors for aspiration pneumonia. Dysphagia impairs the normal swallowing mechanism, while GERD can lead to the backflow of acidic gastric contents into the esophagus and potentially the lungs. These conditions make it easier for aspirated material to enter the lungs, leading to inflammation and infection.

Question 2: Why was oxygen therapy initiated for Francis?

Francis presented with low oxygen saturation (89% on room air) and signs of respiratory distress, such as tachypnea and cyanosis. Oxygen therapy helps to increase the amount of oxygen in the blood, improve tissue oxygenation, and reduce the work of breathing. It is a critical intervention to stabilize patients with respiratory compromise.

Question 3: What is the importance of obtaining a sputum culture in the management of aspiration pneumonia?

Empirical antibiotic therapy is initially started based on common causative organisms, but a sputum culture provides precise identification of the pathogens involved. This allows for adjustment of antibiotics to ensure they are effective against the identified bacteria, improving treatment outcomes and reducing the risk of antibiotic resistance.

Question 4: Why is it essential to keep Francis NPO initially and then adjust her diet to thickened liquids and pureed foods?

Patients with dysphagia are at high risk of aspirating food and liquids into their lungs, which can worsen aspiration pneumonia. An initial NPO status reduces this risk. After a swallowing assessment, adjusting the diet to thickened liquids and pureed foods helps ensure safer swallowing by slowing down the transit of food and allowing better control, thus reducing the likelihood of aspiration.

Med Surg Case Study #33: Francis Jordan