Community Acquired pneumonia by saeid kashefi- SOAP

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SOAP :

Pneumonia SOAP 1 10/24/2014 Saeid kashefi 2 nd year post.bacc November 12, 2011, has been proclaimed World Pneumonia Day . Every 20 seconds a child dies from pneumonia

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2 Fluid and pus filled air space contains bacteria

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3 Who Gets Pneumonia? Anyone can get pneumonia, but some people are at a higher risk than others. Risk factors include: Cigarette smoking Recent viral respiratory infection—a cold, laryngitis, influenza , etc . Difficulty swallowing (due to stroke, dementia, Parkinson's disease, or other neurological conditions) Chronic lung disease such as COPD, bronchiectasis, or cystic fibrosis H eart disease, liver cirrhosis, or diabetes   Living in a nursing facility Impaired consciousness (loss of brain function due to dementia, stroke, or other neurologic conditions) Recent surgery or trauma Having a weakened immune system due to illness, certain medications, and autoimmune disorders

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Community-acquired Pneumonia (CAP) was the 4 th leading cause of death in the world in 2012 according to the WHO and 6 th leading cause of death in the U.S. It’s a Inflammation of one or both lungs. What Causes Pneumonia ? The infection may be bacterial, viral, fungal . Pneumonia is extremely contagious Pneumonia can be a serious and life-threatening infection. This is true especially in the elderly, children, and those who have other serious medical problems, such as COPD, heart disease, diabetes, and certain cancers . 4 Pneumonia

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7 Pneumonia confirmed by chest X-ray testing . ( dense white patch ) CT scan With pneumonia, sputum is sometimes bloody Sputum Gram Stain and culture Pulse oximetry Routine lab testing – CBC BMP ( basic metabolic panel ) LFTs ABG ( arterial blood gas ) Diagnosis of Pneumonia

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8 How do we classify pneumonia? Nosocomial Pneumonias

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9 Treatment of Community Acquired Pneumonia (CAP)

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10 Table 116-8 Evidence-Based Empiric Antimicrobial Therapy for Pneumonia in Adults Clinical Setting Usual Pathogens Empiric Therapy Outpatient/community acquired Previously healthy S. pneumoniae , M. pneumoniae , H influenza, C. pneumoniae , M. catarrhalis Macrolide/ azalide , or tetracycline Comorbidities (diabetes, heart/lung/liver/renal disease, alcoholism Fluoroqinolone d or -lactam + macrolide b Elderly S. pneumoniae , Gram-negative bacilli Piperacillin / tazobactam or cephalosporin e or carbapenem f Inpatient/community acquired Non-ICU S. pneumoniae, H. influenza, M. pneumoniae, C. pneumoniae, Legionellasp . Fluoroquinolone d or -lactam + macrolide b ICU S. pneumoniae, S.aureus, Legionella sp, gram-negative bacilli, H. influenza β -lactam + macrolide or fluoroquinolone ; piperacillin / tazobactam meropenem or cefepime + fluoroquinolone , β -lactam + AMG + azithromycin β -lactam + AMG + respiratory fluoroquinolone If MRSA suspected Above + vancomycin or linezolid Hospital acquired, ventilator associated, or healthcare associated No risk factors for MDR pathogens S. pneumoniae , H. influenzae , MSSA enteric Gram-negative bacilli Ceftriaxone or fluoroquinolone d or ampicillin/ sulbactam or ertapenem or doripenem Risk factors for MDR pathogen P. aeruginosa , K. pneumoniae (ESBL), Acinetobacter sp., Antipseudomonal cephalosporin e or antipseudomonal carbapenem or -lactam/-lactamase + antipseudomonal fluoroquinolone d or AMG If MRSA or Legionella sp. suspected Above + vancomycin or linezolid Aspiration Mouth anaerobes, S. aereus , enteric Gram-negative bacilli Penicillin or clindamycin or piperacillin / tazobactum + AMG

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11 SOAP

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Bilateral pneumonia and ARDS Right sided pneumonia Septic shock Problem List 12

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C/O sudden onset breathlessness since morning (3 AM) Associated with shivering, severe sweating Subjective Evidence 13

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Physical Examination: RR-35/min SpO2-60 % ( 95-100 %) RS : Right B/L basal creps + Objective Evidence 14

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WBC : 22.0 x10 3 cells/mm 3 N : 90.9 (35-75)% L : 4.9 (20-45)% Routine Biochemical Investigation 15

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Bilateral pneumonia and ARDS Right sided pneumonia Septic shock FINAL DIAGNOSIS 16

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17 ETIOLOGY

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Table 116-6 Pneumonia Classifications and Risk Factors Type of Pneumonia Definition Risk Factors Community acquired (CAP) Pneumonia developing in patients with no contact to a medical facility Age >65 years Diabetes Mellitus Asplenia Chronic cardiovascular, pulmonary, renal and/or liver disease Smoking and/or alcohol abuse Healthcare associated (HCAP) Pneumonia developing in patients not in medical facility but two or more risk factors for MDR pathogens Recent hospitalization 2 days within past 90 days Nursing home or long-term care facility resident Recent (past 30 days) antibiotic use, chemotherapy, wound care or infusion therapy either at a healthcare facility or home Hemodialysis patients Contact with a family member with infection caused by MDR pathogen Hospital-acquired (HAP) Pneumonia developing >48 hours after hospital admission Witnessed aspiration COPD, ARDS, or coma Administration of antacids or H2-antagonists Supine position Enteral nutrition, nasogastric tube Reintubation , tracheostomy, or patient transport Prior antibiotic exposure Head trauma, ICP monitoring Age >60 years See healthcare associated for MDR risk factors Same as hospital acquired 18

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Yes , therapy is indicated to Reduce morbidity and mortality Prevent complications and Improve quality of life. Assessment if therapy is indicated ? 19

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Drug with Dose & Route 12/10   13/10   14/10 15/10 16/10 Generic Name Dosage form Brand Name   1 ICU 2 ICU 3 ICU 4 5 Piperacillin / Tazobactam Inj. Tazillin 4.5 g IV   Stat in 50 ml of NS over 1 hrs   Over 30 min Methylprednisolone Inj . Solumedrol 40 mg in 40 ml NS Q8H         Dopamine Inj. Dopamine 6 ml/ hr       Ipratropium (20mcg/1puff) Levosalbutamol (50mcg) Neb. Duolin Q6H       Pantoprazole Tab. Pan 40mg 1-0-0 (b/f)       Paracetamol Tab. Dolo 650mg SOS       Chlorpheniramine Inj Avil IV 1amp SOS       Ondansetron Inj. Emeset 4mg IV SOS         NA Inf Na         Montelukast Tab Montair Stat-1         Salbutamol (100ml) Neb Asthalin Stat       Chlorpheniramine (4mg/5mL) / Dextromethorphan (10mg) Syp Aerodil 2tsp 1-0-1           Cap Becelac forte 1-1-1       20

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Assessment of Current Therapy 22

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Class : Piperacillin : extended-spectrum beta-lactam antibiotic of the ureidopenicillin class. Tazobactam : β- lactamase inhibitor. MOA : Piperacillin inhibits bacterial cell wall synthesis . Tazobactum inhibits the action of bacterial β -lactamases. Indication : is indicated for Community-acquired pneumonia (moderate severity only ), Nosocomial pneumonia (moderate to severe ) Justification : It is correctly indicated according to the Infectious Diseases Society of American Guidelines on the Management of CAP in Adults. Dose , dosage and schedule were found to be correct. ADR : Prolongation of bleeding time, anaphylaxis, nausea, vomiting , diarrhea. Inj. Tazillin 4.5 g IV ( Piperacillin / Tazobactam ) Stat in 50 ml of NS over 1 hrs Days 1-5 23

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Class : Co rticosteroid drug MOA : It inhibit the potent mediators of inflammation such as prostaglandins and leukotrienes . Indication : It is indicated for breathlessness Justification : It is correctly indicated as patient was having breathlessness as symptoms of pneumonia Dose, dosage and schedule were found to be correct. ADR : Hypercalciuria , hypokalemic alkalosis, CHF, PUC, HTN, viral infections , itching, allergic skin reactions. Inj. Solu medrol 40 mg (Methylprednisolone) in 40 ml NS Q8H DAY 1 24

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MOA : increases blood pressure by acting on both α and β - 1 receptors. Indication : It is given for the treatment of severe hypotension and septic shock Justification : It is correctly indicated as the patient had hypotension on day 1 and septic shock Dose , dosage and schedule were found to be correct. ADR : nervousness , headache, dysrhythmias, palpitations, chest pain, dyspnea, nausea, and vomiting. INJ. Dopamine 6 ml/ hr DAY 1 25

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Class : anticholinergic agent/ Stimulates β- receptors MOA : Ipratropium bromide : decreased contractility of smooth muscle/ Levosalbutamol : Stimulates β -receptors Indication : breathlessness. Justification : It is indicated correctly because patient had breathlessness from day 1 Dose, dosage and schedule were found to be correct. ADR : tremor , tachycardia, leg cramps , dizziness, vomiting Neb. Duolin (Ipratropium ( 20 mcg/1puff ) Levo -salbutamol ( 50 mcg )) Q6H DAYS 1-3 26

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Class : proton pump inhibitor (PPI) MOA : Pantoprazole inhibit H+/K + - ATPase enzyme Indication : for prevention of gastric irritation Justification : It is indicated to prevent gastric irritation due to poly pharmacy Dose , dosage and schedule were found to be correct. ADR : Weakness, dizziness, nausea, vomiting, anxiety, dyspnea, pain, pharyngitis, cough, arthralgia, rhinitis, chest pain, bronchitis, backache, urinary frequency, UTI, hyperlipidemia . Tab. Pan 40 mg (Pantoprazole) 1-0-0 (b/f) Day 1-5 27

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Class : NSAIDs (antipyretic and analgesic) Indication : for chills (as symptoms of pneumonia) as well as RA. Justification : It is indicated correctly because the patient had chills on day 1 and RA according to medical history. (Patient has been taking paracetamol ) Dose, dosage and schedule were found to be correct. ADR : Bronchospasm , blood dyscrasias , centribular necrosis, liver damage, hypoglycemic coma, hepatic necrosis, liver failure, skin rashes, GI adverse effects. Tab . Dolo 650mg ( Paracetamol ) SOS DAYS 28

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Class : first-generation alkylamine antihistamine MOA : it is H1-receptor antagonist Indication : cough, running nose (since 4 days back) Justification : It is correctly indicated as the patient had cough Dose , dosage and schedule were found to be correct. ADR : Blurred vision, dry eyes, mydriasis , drowsiness, constipation, fatigue , headache, dizziness, psychomotor impairment, dry mouth, gastrointestinal disturbances. Inj . Avil IV (Chlorpheniramine) 1amp SOS 29

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30 Inj. Emeset 4mg IV ( Ondansetron ) S.O.S. days 1-2 Class : prevent nausea and vomiting caused by cancer chemotherapy, radiation therapy, and surgery . MOA : serotonin (5HT3) antagonist Indication : given for vomiting Justification : It is given due to patient suffering from vomiting. Dose, dosage and schedule were found to be correct. ADR : Headache, dizziness , drowsiness, tiredness, or constipation may occur .

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Class : catecholamine (adrenergic agonists) MOA : norepinephrine stimulates cardiac contractility . Indication : hypotensive states, septicaemia Justification : It is correctly indicated as the patient had hypotension and septic shock. ( Norepinephrine is used to treat shock, because it increases vascular resistance and, therefore, increases blood pressure. Other actions of norepinephrine are not considered to be clinically significant .) Dose, dosage and schedule were found to be correct. ADR : ausea , stomach upset, skin rash, acute toxicity. Inf. NA ( Noradrenaline) day-2 31

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Class : leukotriene receptor antagonist MOA : Montelukast selectively antagonizes LTD4, preventing smooth muscle contraction. Indication : breathlessness Justification : This reduces the bronchoconstriction caused by the leukotriene, and results in less inflammation Dose, dosage and schedule were found to be correct. ADR : Angioedema, headache, restlessness, abdominal pain, agitation, oedema , allergy anaphylaxis. Tab . Montair ( Montelukast ) Stat-1 DAY- 1 32

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Class : β 2 - agonist MOA : direct-acting sympathomimetic which producing bronchodilating effects. Indication : breathlessness Justification : It is given correctly as the patient complained of breathlessness Dose , dosage and schedule were found to be correct. ADR : Fine skeletal muscle tremor especially hands, tachycardia, palpitations, muscle cramps, headache, angioedema, urticaria , hypotension and collapse . Neb . Asthalin (Salbutamol (100ml)) Stat 33

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Class : Lactobacillus acidophilus 2000lacs, Folic acid 1.5 mg, Vit.B12 15 mcg , Niacinamide 100 mg, Calcium pantothenate 50 mg, Biotin 100mcg . MOA : It helps to prevent harmful bacterial growth. Indication : Used For vitamins and minerals deficiency due to diarreha . Justification : It is given correctly as in cases of mild Antibiotic induced diarrhea. Dose , dosage and schedule were found to be correct. Cap Becelac forte 1-1-1 day 4-5 34

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Class : Antitussive agent MOA : Chlorpheniramine is an H1-antagonist . Dextromethorphan acts as antagonist to the NMDA glutamatergic receptor Indications : used for treatment and prevention of cough. Justification : correctly indicated as patient suffered from cough. Dose , dosage and schedule were found to be correct . ADR : Dependency, dizziness, drowsiness, vomiting, restlessness, mental confusion, excitation Syrp . Aerodil (Chlorpheniramine (4mg/5mL)/ Dextromethorphan ( 10mg)) 2 tsp 1-0-1 day 4 35

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PLANNING 36

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Eradication of the offending organism through selection of the appropriate antibiotic and complete clinical cure To decrease morbidity and mortality To prevent complications To relieve patient symptoms To improve quality of life Goals of Therapy 37

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Monitoring Parameters Therapeutic Monitoring Toxicity Monitoring vitals, RR, SpO2- chest Xray RS :B/L basal creps +, WBC: plateleate Electrolytes Heart rate Fatiguability Pedal edema Jaundice Input/output 38

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Patient having high TSH which indicated for hypothyroidism. Blood urea nitrogen level Ondansetron is not for preventing nausea or vomiting that is caused by factors other than cancer treatment or surgery . Points to Physician 39

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Points to the patient : You have infection in your lung and it can be treated if you adhere to your therapy. It is contagious which can be spread easily. Hence care must be taken. Points to Patient 40

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How to Strengthen Your Lungs After Having Pneumonia Method 1: Performing Breathing Exercises 1-Practice deep breathing . 2-Do pursed-lip breathing . 3-Try breathing from your diaphragm 4-Practice huff-cough breathing. Life Style Modification 41

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42 At Home Rest as much as possible to help speed your recovery. Drink plenty of fluids throughout the day . Take the entire course of any prescribed medications. Get enough vitamins and minerals.

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43 Tab pan 40 mg 1-0-0 Tab tazillin 4.5 gm Q8h Syr aerodil 2tsp 1-0-1 Tab dolo 650mg sos Points to Patient on Discharge Medication

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44 It is antibiotic which is indicated for treatment of pneumonia. It should be taken one tablet each every 8 hours. You may have nausea, vomiting and diarrhea as side effects. Tab tazillin 4.5 gm Q8h Tab pan 40 mg 1-0-0 It is indicated to prevent gastric irritation due to multi drugs. One tablet should be taken 30 min. before breakfast. You may have weakness, dizziness, nausea, vomiting or anxiety as side effects.

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45 It is indicated to reduce your cough. It should be taken 2 tea spoon each 12hours. You may have dizziness, drowsiness , vomiting, restlessness as side effects. Syr aerodil 2tsp 1-0-1 Tab dolo 650mg sos It is indicated for your Rheumatoid Arthritis . You should take it whenever there is pain in your joints . You may have nausea, vomiting and diarrhea as side effects.

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To review SOS Follow up/Review 46

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47

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