Pulmonary Medicine and Nursing Practice

This document is a compilation of past papers and assignments related to pulmonary medicine and nursing practice. It includes excerpts from several sources, such as textbooks, articles, and online resources. The content covers topics like respiratory care principles, community-acquired pneumonia, hospital-acquired pneumonia, and more. It provides a valuable resource for students looking for past papers and assignments on this topic.

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CRITICAL CARE
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Critical Care 2
A Patient with Pneumonia
Question 1
Pneumonia is a disease caused by infections of the lungs as a result of bacterial or viral
attacks. It causes a consolidation and collapse of the lungs thus interfering with respiration in
patients. Anyone is at risk of suffering from pneumonia but the elderly and young children are
more susceptible to this disease due to a weaker immune system (Ruuskanen et a., 2011, p.
1266). The symptoms of pneumonia among the elderly depend on their overall health and
functional status. In the case study provided, we are told of the condition of Mr. Hunter who is
an 89-year old man. There are specific considerations that a registered nurse must understand
regarding the clinical manifestations of pneumonia among the elderly like in Mr. Hunter’s case.
Below, we will discuss some of these considerations.
It is important to note that the lungs and the nerves that connect to the lungs among the
elderly are not always very reactive and responsive. The lungs are therefore weak and less
sensitive thus making them more susceptible to pneumonia (Saguil and Fargo, 2012, p. 355).
From the scenario presented, we are informed that Mr. Hunter has developed hypoxemia. The
compliance of the chest wall progressively reduces as one gets older. The airway may start
closing at small volumes due to a loss of the supporting tissues that surround the airways. As a
result, the patient suffers a progressive decline in the volume of saturation of oxygen which may
cause hypoxemia.
It is also important to note that aging causes the inflexibility of the lungs thus leading to a
collapse of the air sacks responsible for oxygenation. This is especially more common among the
elderly suffering from pneumonia, as is the case of Mr. Hunter (Sue Eisenstadt, 2010, p. 18). The

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result is a development of a shortness of breath a condition known as dyspnea. Additionally, the
elderly like the patient in our scenario have increased morbidity and mortality. This combined
with his condition of pneumonia increases the risks of developing cachexia which can be
described as unintentionally losing weight (Marrie, Bartlett and Thorner, 2013). Furthermore,
due to the worsening situation of his chronic obstructive airways disease, he develops tachypnea
as the body attempts to compensate for the low oxygen concentration that is said to be only 82%.
The pleuritic pain that he develops is as a result of deep breathing and coughing. Due to the
infection of the lungs as a result of pneumonia, his sputum becomes purulent which can be
characterized by a color similar to rust.
Question 2
Pneumococcal pneumonia is a major cause of respiratory failure among the elderly thus
causing several deaths if the situation is not addressed. The respiratory failure exists in two forms
that are the ventilatory failure and hypoxemic respiratory failure. The mechanical changes of the
lungs due to pneumonia are the major causes of ventilatory failure. An inflammatory reaction
normally takes place in the alveoli thus producing an exudate that fills alveoli (Wagner and
West, 2012, p. 219). This filling, however, happens at a functional residual capacity that is
slightly less than normal thus leading to a reduction in the volume of functional residual
capacity. As a result, the total lung compliance is reduced and the work of breathing is increased
hence interfering with ventilation and diffusion (West, 2012, p. 73). Additionally, the white
blood cells migrate and fill the alveoli.
Studies have further revealed that secretions and mucosal edema associated with
pneumococcal pneumonia cause a partial occlusion of the alveoli and bronchi and thus the areas
of the lungs are not adequately ventilated. The result is that the oxygen tension of the alveoli is

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reduced. This further reduces the dynamic compliance of the remaining ventilated lung which
thus increases the work of breathing as shown by Mr. Hunter’s low saturation of oxygen.
Additionally, the patient becomes breathless and tachypneic accompanied with an increase in the
pleuritic pain during inspiration.
A mismatch between ventilation and perfusion during the later stages of pneumococcal
pneumonia causes hypoxemia as is evidenced by the scenario provided in our case study. The
perfusion-ventilation mismatch occurs due to hypoventilation in the affected areas of the lungs
(Petersson and Glenny, 2014). As a result, the venous blood that enters into the pulmonary
circulation travels through the area of the lung that is under-ventilated and comes out poorly
oxygenated via the left side of the heart. This mixing that occurs between oxygenated and poorly
oxygenated blood eventually lead to hypoxemia (Petersson and Glenny, 2014). Another factor
that causes hypoxemia in pneumococcal pneumonia is the persistent pulmonary blood flow to the
consolidated lung. This persistence in the flow results from the failure of the mechanism of
hypoxic pulmonary vasoconstriction. This, according to Hough (2013), affects the diffusion of
oxygen from the alveoli to the blood (p. 8).
Question 3
Hospital-Acquired Pneumonia
A patient develops hospital-acquired pneumonia within 48 hours of admission to the
hospital. It is mostly caused by micro-aspiration of bacteria that attack the upper airways in the
critically ill patients. It can also be caused by inhalation of aerosols that contain influenza virus
or Aspergillus sp (Barbier et al., 2013, p. 217). Overall, the greatest risk factor for hospital-
associated pneumonia is an endotracheal intubation that is combined with mechanical

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ventilation. This is because the endotracheal intubation interferes with the airways prejudices
mucociliary clearance and cough, and encourages the micro-aspiration of the secretions full of
bacteria that are located above the endotracheal tube cuff that is normally inflated. According to
Victor (2011), this type of pneumonia is characterized by chest pains, dyspnea, cough, fever,
malaise, increased respiratory rate and heart rate, increased purulent secretions, and hypoxemia
(p. 250).
Community-Acquired Pneumonia
Community-acquired pneumonia, on the other hand, develops among individuals who
have limited or no contact with medical institutions. The common causative agents of this
condition are Haemophilus influenzae and Streptococcus pneumoniae. There are several
organisms that cause community-acquired bacteria, ranging from bacteria, fungi, and viruses
(Marti and Esperatti, 2016, p. 116). The symptoms of this infection include malaise, fever,
dyspnea, chest pains, cough, and chills among others. The cough is normally productive in the
elderly patients as is the case with Mr. Hunter. The chest pain is normally pleuritic that is
adjacent to the infected area. The signs of community-acquired pneumonia include crackles,
tachycardia, tachypnea, fever, and bronchial breath sounds among others (Marrie, Bartlett and
Thorner, 2013). The treatment of this condition is based on empirically chosen antibiotics.
Aspiration Pneumonia
Aspiration pneumonia results from an inhalation of toxic substances that include gastric
contents into the lungs. It thus causes an inflammation of the lungs, a condition known as
chemical pneumonitis, lung abscess, or airway obstruction (Sue Eisenstadt, 2010, p. 20). The risk
factors for aspiration pneumonia may include dental procedures, gastro-esophageal reflux

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disease, impaired swallowing, nasogastric tube placement, and endotracheal intubation among
others. The signs and symptoms of aspiration pneumonia include a cough, fever, dyspnea, and
chest pains. Treatment normally involves a combination of antibiotics, supplementary oxygen,
and mechanical ventilation (Ebihara, Ebihara and Kohzuki, 2012, p. 30). It is advisable to
optimize dental hygiene to help in preventing the development of aspiration pneumonia.
Question 4
Nursing care plans for patients suffering from pneumonia consist of supportive measures
such as oxygen therapy that is humidified to manage hypoxemia. Additionally, there is always a
form of mechanical ventilation to treat respiratory failure. Furthermore, a care plan involving a
fluid intake and a high-calorie diet could also be initiated. Below, we will discuss some of the
nursing care plans to help in caring for Mr. Hunter.
Promote Airway Clearance
Ineffective airway clearance could be described as the inability of the patient to clear
obstructions such as secretion from the respiratory tract to maintain a clear airway. This
condition could be related to pleuritic pain that is experienced by Mr. Hunter. Additionally, it is
related to an increase in the production of sputum. It could be characterized by a change in
respiratory rates, dyspnea, and coughs among others. The interventions for this care are normally
aimed at displaying patent airways with the absence of dyspnea.
The following are some of the interventions that could be employed to achieve the above-
mentioned aims. Firstly, Mr. Hunter’s bed should be elevated and the nurse should frequently
change the patient’s position. This intervention helps to lower the diaphragm and enhance the
expansion of the chest and the aeration of the lungs and as a result, expectorate secretions.

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Secondly, it would be important to auscultate the lung fields. This is done to identify areas with
an absence of airflow and to detect adventitious breathing (Gulanick and Myers, 2011, p. 431). It
is important to note that a decrease in the airflow occurs in the areas that contain consolidated
fluids. The crackles and wheezes are also heard due to an accumulation of fluids, airway
obstructions, and thick secretions.
Managing Acute Pain
Acute pain may be related to persistent coughing and a possible inflammation of the lung
parenchyma. Some of its characteristics such as restlessness and pleuritic chest pains are
exhibited by Mr. Hunter. The first intervention to this condition could be an assessment of the
characteristics of the pain. The nurse investigates the changes in pain location and its intensity. It
is important to note that chest pains in some instances herald the onset of pneumonia associated
complications. Secondly, it is important to offer the patient oral hygiene on a frequent basis. This
is due to the fact that an oxygen therapy and mouth breathing aid in drying out the mucous
membranes thus causing potential discomforts (Dunphy et al., 2015, p. 457). Additionally, the
nurse could instruct the patient on techniques of splinting the chest during coughs. This helps in
controlling the discomfort of the chest while enhancing effective coughing at the same time.
Managing Impaired Gas Exchange
This could be described as a deficit or excess oxygenation and elimination of carbon (IV)
oxide between the capillary and alveoli. As exhibited by Mr. Hunter, this condition is
characterized by dyspnea, hypoxemia, restlessness, and tachycardia. The nurse could apply the
following interventions to help in addressing this issue. Firstly, the nurse could monitor the
patient’s heart rate. Tachycardia, which is an increase in heart rate, is normally present due to

Critical Care 8
fever and dehydration. It could also result from the condition of hypoxemia (Doenges,
Moorhouse and Murr, 2016, p. 61). The aim, therefore, is to ensure that the heart rate does not
exceed 100 beats per minute. Secondly, it is important to monitor the body temperature to help in
reducing fevers and chills. The temperature, as indicated in the case study should not exceed 38.5
degrees Celsius. This is because high fevers usually increase the consumption of oxygen and the
metabolic demands thus altering cellular oxygenation (Dunphy et al., 2015, p. 375). Thirdly, the
administration of oxygen therapy is important to maintain the saturation of oxygen above 90% as
highlighted in the case study. The oxygen is administered cautiously using the appropriate
means, which in most cases is normally the Hudson mask.
Question 5
It is greatly important to monitor Hunter’s heart rate to ensure that it does not exceed 100
beats per minute. It is important to note that pneumonia could lead to a possible condition of
hypoxemia which may further result in tachycardia. Additionally, pneumonia could possibly
push the heart into abnormal rhythms such as atrial tachycardia due to the dilation of the blood
vessels located in the right side of the heart thus throwing off the heart’s electrical system (Hess,
2011, p. 523). If the patient’s heart rate is therefore not monitored, they could develop
tachycardia which could disrupt the normal operation of the heart and lead to a sudden cardiac
arrest, heart failure, stroke or a possible death at worst.
It is additionally important to monitor the level of saturation of oxygen and ensure that it
does not fall below 90%. The aim is to ensure that the saturation of oxygen does not fall too low
so as to help in managing hypoxemia. Saturation of oxygen below 90% could be an indication of
hypoxemia and respiratory failure (LeMone et al., 2015, p. 1255). A high flow oxygen therapy is

Critical Care 9
thus necessary to ensure that the saturation of oxygen is more than 92 which is considered
normal.
Finally, the consultant recommends that Mr. Hunter’s temperature should be maintained
at 38.5 degrees Celsius. Monitoring the body temperature helps in reducing fever and chills thus
enhancing comfort. This is because high fevers that are commonly experienced in bacterial
pneumonia and influenza which we are also informed that Mr. Hunter has a history of, massively
increases the metabolic demands of the body. It is also important to note that fevers increase the
consumption of oxygen and as a result, alter the cellular oxygenation.
Question 6
Strategies
As a registered nurse, it is imperative to convince Mr. Hunter that he needs the oxygen
therapy to help in maintaining his level of saturation of oxygen within the normal range. In the
presented scenario, we are informed that the patient became agitated and requests that the
oxygen therapy is stopped. Legally, the patient has the right to refuse any form of medication but
the nurse has an ethical responsibility to make the patient understand the importance of any form
of medication to their health (Jones, Shaban and Creedy, 2015, p. 192). The registered nurse
could thus use some strategies to try and convince Mr. Hunter that refusing oxygen could have
several implications.
Firstly, the nurse could actively engage Mr. Hunter in a conversation and the overall
decision-making process regarding his health. This strategy will make the patient feel more
involved in the medical processes that are aimed at addressing his condition. As a result, the
quality of health may be improved if the patient sees the sense in changing his mind and once

Critical Care 10
again accepting the oxygen therapy (Cashin et al., 2017, p. 260). Secondly, the nurse could
decide to involve the family of Mr. Hunter to try and talk him out of his decision. It is
understandable that an individual feels more connected to their families and therefore it could be
easier to have a family member talk to Mr. Hunter about the possible implications of refusing
oxygen.
Managing the Situation
As the registered nurse tasked with caring for Mr. Hunter, I would endorse a social
support mechanism and family involvement. Involving the family of the patient would be crucial
in improving oxygen adherence. A social support mechanism also encourages compliance with
oxygen therapy. I would additionally propose a switch to a more convenient source of oxygen
that is maybe portable as the patient could possibly be tired of having to lie down on bed day and
night. This type of source of oxygen enables the patients to be independent and ambulatory.
Furthermore, I would encourage frequent patient-doctor communication that is sincere to
improve the adherence to oxygen therapy.
Question 7
From the scenario presented in Mr. Hunter’s case study, I have been able to learn two
important things. The first is that critically ill patients are at a great risk of deteriorating if their
health conditions are not addressed promptly with the most appropriate interventions. Secondly,
a patient has every right to refuse any form of medication and they, therefore, control their own
treatment (Brown et al., 2017, p. 89). In my future practice as a registered nurse, I would always
ensure that I prioritize the safety and well-being of all my patients. Therefore, I will always act
as soon as possible to care for patients and prevent the deterioration of their health conditions.

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Additionally, since my number one priority as a nurse is to improve the quality of health and
ensure patient safety, I will always try my best to make the patients understand the importance of
any form of medication and the implications associated with refusing medication.
One of the NMBA nursing standards that relate to what I learned, in this case, is; provide
safe, appropriate and responsive quality nursing practice. This will help in changing my practice
several ways that may include practicing within my scope, appropriate delegation of aspects of
practice to enrolled nurses, and practice in accordance to the relevant rules, regulations,
standards, and practices.

Critical Care 12
References
Barbier, F., Andremont, A., Wolff, M. and Bouadma, L., 2013. Hospital-acquired pneumonia
and ventilator-associated pneumonia: recent advances in epidemiology and
management. Current opinion in pulmonary medicine, 19(3), pp.216-228.
Brown, D., Edwards, H., Seaton, L. and Buckley, T., 2017. Lewis's Medical-Surgical Nursing:
Assessment and Management of Clinical Problems. Elsevier Health Sciences.
Cashin, A., Heartfield, M., Bryce, J., Devey, L., Buckley, T., Cox, D., Kerdo, E., Kelly, J.,
Thoms, D. and Fisher, M., 2017. Standards for practice for registered nurses in
Australia. Collegian, 24(3), pp.255-266.
Doenges, M.E., Moorhouse, M.F. and Murr, A.C., 2016. Nursing diagnosis manual: Planning,
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science of advanced practice nursing. FA Davis.
Ebihara, S., Ebihara, T. and Kohzuki, M., 2012. Effect of aging on cough and swallowing
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Hess, D., 2011. Respiratory care: principles and practice. Jones & Bartlett Learning.
Hough, A., 2013. Physiotherapy in respiratory care: a problem-solving approach to respiratory
and cardiac management. Springer.

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Jones, T., Shaban, R.Z. and Creedy, D.K., 2015. Practice standards for emergency nursing: an
international review. Australasian Emergency Nursing Journal, 18(4), pp.190-203.
LeMone, P., Burke, K., Dwyer, T., Levett-Jones, T., Moxham, L. and Reid-Searl, K.,
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Victor, L.Y., 2011. Guidelines for hospital-acquired pneumonia and health-care-associated
pneumonia: a vulnerability, a pitfall, and a fatal flaw. The lancet infectious diseases, 11(3),
pp.248-252.

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Wagner, P.D. and West, J.B., 2012. Ventilation-Perfusion. Ventilation, Blood Flow, and
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