Clinical Symptoms, Diagnosis And Treatment Of Homeless Man With Influenza And Hypertension

Patient Observation and Background

Discuss about the Factors affecting the development of drug reactions.

The patient, Jim is an elderly 58 year old male who seems to be undernourished suggestive of underprivileged living condition. He seems to have elevated body temperature indicating feverish conditions along with inflammation and oedema in tonsils, ear and pharynx. He is having incessant clear nasal and muscle pain all of which suggests flu like clinical symptoms (Essen et al., 2014). The discharge sample is sent to the microbiological lab for diagnosis and the results have yet to arrive. The patient’s heart rate is marginally elevated to 105 beats per minute (BPM) and respiratory rate (RR) is also seemingly normal, 18 respirations per minute (RPM). The breathing of the patient is still difficult with bilateral wheezing with no crackles visible in lungs, so no symptoms of bronchitis are observed. The cardiac output of the patient has come down to threshold value and no sings or murmuring or gallops is observed. The blood pressure of the patient is very high, 158/86mmHg, this could be due to hypertension, which the patient seems to have a previous history of, but does not take medication in spite of being previously prescribed (Bromfield & Muntner, 2013).  Although the patient came in the day before with chest pain, muscle soreness, fatigue and malaise which seemed to have been controlled down but the patient still has rhinorrhea and muscle tenderness. The neurological test of the patient seems to be positive; Jim seems alert and oriented and is responding to the parameters of Glasgow Coma Scale (GCS) properly. The patient seems to be sweaty, which could be due to his hypertensive habit. After his hospitalization, oseltamivir is commenced to on suspicion of influenza (Dobson et al., 2015). Jim used be a vigorous smoker but due to his poor economic conditions, he cannot afford much cigarette, but still smokes 5-10 sticker per day.

Nursing problem: Risk of spread of infection
Underlying cause or reason: Influenza is a highly contagious virus spread via airborne droplets and direct contact. Immuno-compromised patients in the hospital setting are at higher risk of contracting disease resulting in adverse events.
Goal of care	Nursing interventions/actions	Rationale	Indicators your plan is working
To prevent and control the spread of influenzawithin the healthcare facility and the community.	Assessment of respiratory status, depth, accessory muscle usage and breathing pattern.Auscultation of the lung field to check for wheezing, crackles and any other breath or heart related sounds.Monitor patient for coughing symptoms, sputum generation and note the amount.Position patient in such a way that they can get air, as in Fowler’s position.Change patient position every couple of hours.Administer bronchodilators if necessary.Perform postural draining if necessaryAdminister or encourage more fluid intake.Commence deep breathing exercises.Make sure that the patient is in comfortable conditions.Keep the patient in isolation, since this a very contagious diseases (Ang et al., 2010).Instruct the patient to be careful about his hygiene and wash hands with in contact with his own mucous.Administer detailed antibiotic treatment as soon as the reports from microbiology lab arrive.	Infection may cause bronchial swelling, mucous accumulation in air sacs which causes narrowing of air passage which leads to distress while breathing. Care has to be taken so that the infection does not spread further and cause more complication, since the patient is already suffering from hypertension.If any breathing sound is observed like wheezing in case of the patient, then it means that the air passage is blocked. This may cause edema and bronchospasmic symptoms in the patient (Lionakis et al., 2012).If mucous colour is yellow or greenish then it can be confirmed that the patient is undergoing pathogen infection (Iwasaki & Pillai, 2014).Fowler’s position help the patient achieve maximum spreading of lung tissues to increase air intake (Cicolini, Gagliardi & Ballone, 2010). The pulmonary secretions can be removed if the positions are changed.Bronchodilators smoothen the muscles and helps in decreasing spasms and improve ventilation (Lionakis et al., 2012)..Draining the posture helps in clearing out the mucous by the help of gravity and moves the secretions so that they can be expelled out from the body(Cicolini, Gagliardi & Ballone, 2010).Expanding the lungs helps in better breathing and movement of the mucous.Deep breathing also helps moving the mucous as well as helping the patient overcome any possible anxiety.Keeping the patient in an isolated condition will ensure that other patients in the ward do not get infected by the pathogen.Washing hands will ensure that the nursing staff as well as doctors do not get affected from the patient.	Patient is expected to show signs of stability and achieve homeostasis.The respiratory passage of the patient should be cleared.The patient is expected to have clear breathing without any obstruction sounds and optimal gas exchange will seem to take place.The mucous secretion will stop.The headache and muscle tenderness willdecrease.The feverish symptoms will go away and normal body temperatures will be observed.
Nursing problem: Self care deficit
Underlying cause or reason: The patient is homeless, living below poverty conditions where sanitation is very low.
Goal of care	Nursing interventions/actions	Rationale	Indicators your plan is working
Provide medication for his hypertensive condition and teach patient about smoking	He needs to be made aware of the ill hazards of smoking in his condition to improve his health. Jim needs to be convinced to take medication for his hypertension condition and made aware of the repercussions of avoiding it.	Smoking will induce his hypertensive condition and the progression might cause cancer	The hypertension symptoms will decrease.
Nursing problem: Risk of imbalanced fluid volume
Underlying cause or reason: The febrile condition followed by influenza infection, has rendered the patient to lose a lot of fluid. His current living conditions also do not allow him to stay hydrated.
Goal of care	Nursing interventions/actions	Rationale	Indicators your plan is working
Restore fluid and ionic balance to maintain homeostasis	Examination needs to be conducted for checking the electrolytes in urine.Commence saline water through intravenous administration.	Intake of fluid helps diluting the mucous and easy expulsion from the nasal cavity (Guppy et al., 2011).The result of the electrolyte analysis will determine the ionic balance of the patient’ body and suggestive kidney failure can be detected (Greenway, Liu, Yu, & Gupta, 2011).	Reduction of sweating in the patient. The patient will seem less stressful.
Nursing problem: Chronic Hypertension
Underlying cause or reason: this a chronic disease developed genetically, but the condition is induced due to his smoking.
Goal of care	Nursing interventions/actions	Rationale	Indicators your plan is working
Immediate commencement of medication for hypertension to stop any further progression of the condition, this may lead to cardiac arrest (Weber et al., 2014).	Lactate level in circulatory system and investigate the cause of wheezing breaths.Provide comfortable surroundings for the patient and calm them down. Assess the reason of fatigue.Check for peripheral nerve pulses.Assess heart tones and breathing sign.Check for signs of cardiac decompensation.	Hypertension conditions often lead to the development of severe cardiac problems like vasoconstriction, ischemic heart disease as well as ventricular rigidity.Depending on the chest X ray, commence necessary measures to control the hypertension (Fuchs et al., 2014).The arterial blood gas levels will determine, whether the patient is undergoing asymptomatic internal stress in the cardiac cavity (Alhamad et al., 2014)..Sweatiness might be resultant of lack of blood in skin periphery.	The chest X ray will determine the cause of wheezing.The patient will show better sign of treatment.The reports might suggest lack of oxygen on the extremities.Relaxed surrounding will help the patient develop less sympathetic stimulation.The administration of anti hypertensive drugs like, diuretics helps controlling the less complicated version of wither stage one or two level hypertension. The patient should feel less tired and his breathing should come down to normal. The sweatiness on his skin should also be lowered.
Nursing problem: Nutrition deficit
Underlying cause or reason: very low economic condition
Goal of care	Nursing interventions/actions	Rationale	Indicators your plan is working
Commence proper nutrition intake	Provide a proper diet plan and maintain the regular dietary intake to maintain the weight	Loss of weight will enhance his condition even more and causes weakness as well as compromise his immune system.	Weight gain and observed healthy conditions.

 

Jim is currently undergoing medication for the suspicion of influenza, he is prescribed, oseltamivir 75mg BD oral tablets, paracetamol 4/24 and fluvax IM stat-dose. Oseltamivir is an inhibitor of neuraminidase for influenza virus, given to patients with symptoms of influenza like Jim, but it is not an alternative to influenza vaccine (Dobson et al., 2015). This is a pro-drug from which is converted to its active state by the esterase enzymes in the liver. Paracetamol is given to Jim to ease his muscle and joint soreness and add some relief to his headache (Jefferies et al., 2016). Jim was also administered with the seasonal flu vaccine separately to ensure that the infection does not reoccur for the season. It has to be made sure that Jim does not show any signs of allergic reaction to any of the administered medication. Although, he only has allergy towards meat of chicken and no known medication, strict monitoring after every couple of hours is recommended.  If any symptoms like, nausea, oedema or inflammation on skin or distress, a practitioner should be informed and alternative medication should be commenced (Alomar, 2014). Jim has a known medical history of hypertension, but does not take any medication to improve his condition. A practitioner should be consulted to provide Jim, some diuretic and angiotensin converting enzyme inhibitor to lower his BP (Weber et al., 2014). These drugs increase urine production to excrete salts and ions quickly and relax the muscle of blood vessels to reduce the pressure of blood in the respiratory cavity.

Prescribed Medication

It is important to teach patient regarding the ill effects of their condition and include them in the care plan. This technique is clinically termed as patient engagement. The given case study is about a homeless man, so it is a little difficult for him to understand the clinical aspect of his condition so it is advisable to provide basic recommendations to reduce his health risk. The patient teaching plan should be performed keeping the patient’s social-economic condition in mind and should be focussed on their current need. Jim is a known smoker with hypertension condition that causes high blood pressure in his respiratory cavity which could lead to more severe issues. Counselling sessions can be arranged for him if any symptoms of addiction are observed. Rehabilitations centres can be contacted who provide free treatments of nicotine addiction. Jim does not take any hypertension medication; he needs to be convinced to receive those medications regularly. Jim can be referred to welfare organization where free of cost medication is offered. Nutrition is a big factor that comes into play in Jim’s health; he lives under condition where poverty is an issue, so he needs as much nutrition as he can get to keep his system from declining. It is important to teach Jim about the effects for malnutrition in his condition, for which he needs to be convinced to take minimum nutrition he finds. Jim also needs to be taught the importance of annual flu vaccines. Jim can be referred to free vaccinisation centres for the betterment of his health.

The patient’s condition seems to have worsened and is shivering in distress. His fever has increased and he is asking for blankets. The thermostat needs to be adjusted to prvide comfortable environment. Medication commencement for hypertension as well as febrile condition. Ooxygen saturation is also low, so using nebulizers to achieve 99% Spo2.

Identification	Jim, a 58 year old homeless elderly male
Situation	The patient was admitted a day before with chest pain, difficulty in breathing, distress and feverish symptoms. The patient’s pharynx and tonsils seemed to be inflamed and sweatiness including headache as well as muscle and joints tenderness. The patient also had continuous nasal discharge, suggesting influenza.
Observation	The patient’s heart beat, oxygen saturation and respiratory rate are marginally normal. Fever is still going on with high blood pressure. The patient seems sweaty and distressed which suggests hypertension.
Background	The patient is a known smoker having 5-10 cigarettes every day. The patient also has a medical history of hypertension for which he does not take any medication. Living in such poor conditions, he is undernourished and reduced body mass. The microbiology reports are yet to arrive.
Agreed plan	Jim has been administered with oseltamivir 45mg orally, paracetamol 4/24 and Influenza vaccination-Fluvax for the season.
Read back	Check for any signs and symptoms of allergic reaction to any of the commenced drugs. Check the X-ray and microbiology reports. Check for respiratory rate and breathing sounds. Garding Check for any signs of continuing flu like symptoms. Check with the nutritionist regarding his diet plan. Report to a practitioner if any of the vitals show abnormality.

References:

Alhamad, E. H., Al-Ghonaim, M., Alfaleh, H. F., Cal, J. P., & Said, N. (2014). Pulmonary hypertension in end-stage renal disease and post renal transplantation patients. Journal of thoracic disease, 6(6), 606.doi:  10.3978/j.issn.2072-1439.2014.04.29.

 Alomar, M. J. (2014). Factors affecting the development of adverse drug reactions. Saudi Pharmaceutical Journal, 22(2), 83-94. https://doi.org/10.1016/j.jsps.2013.02.003

 Ang, B., Poh, B. F., Win, M. K., & Chow, A. (2010). Surgical masks for protection of health care personnel against pandemic novel swine-origin influenza A (H1N1)-2009: results from an observational study. Clinical infectious diseases, 50(7), 1011-1014.https://doi.org/10.1086/651159

 Bromfield, S., & Muntner, P. (2013). High blood pressure: the leading global burden of disease risk factor and the need for worldwide prevention programs. Current hypertension reports, 15(3), 134-136. doi:  10.1007/s11906-013-0340-9.

Cicolini, G., Gagliardi, G., & Ballone, E. (2010). Effect of Fowler’s body position on blood pressure measurement. Journal of clinical nursing, 19(23?24), 3581-3583. https://doi.org/10.1111/j.1365-2702.2010.03418.x

Dobson, J., Whitley, R. J., Pocock, S., & Monto, A. S. (2015). Oseltamivir treatment for influenza in adults: a meta-analysis of randomised controlled trials. The Lancet, 385(9979), 1729-1737. https://dx.doi.org/10.1016/ S0140-6736(14)62449-1

Essen, G. A., Beran, J., Devaster, J. M., Durand, C., Duval, X., Esen, M., … & Kovac, M. (2014). Influenza symptoms and their impact on elderly adults: randomised trial of AS03?adjuvanted or non?adjuvanted inactivated trivalent seasonal influenza vaccines. Influenza and other respiratory viruses, 8(4), 452-462. https://doi.org/10.1111/irv.12245

 Fuchs, T. A., Stehli, J., Bull, S., Dougoud, S., Clerc, O. F., Herzog, B. A., … & Kaufmann, P. A. (2014). Coronary computed tomography angiography with model-based iterative reconstruction using a radiation exposure similar to chest X-ray examination. European heart journal, 35(17), 1131-1136. https://doi.org/10.1093/eurheartj/ehu053

Greenway, Frank, Zhijun Liu, Ying Yu, and Alok Gupta. “A clinical trial testing the safety and efficacy of a standardized Eucommia ulmoides oliver bark extract to treat hypertension.” Alternative Medicine Review 16, no. 4 (2011): 338. https://pdfs.semanticscholar.org/28d0/9bd663aa4934e428accda838a906953a6076.pdf

Guppy, M. P., Mickan, S. M., Del Mar, C. B., Thorning, S., & Rack, A. (2011). Advising patients to increase fluid intake for treating acute respiratory infections. The Cochrane Library. DOI: 10.1002/14651858.CD004419.pub3

Iwasaki, A., & Pillai, P. S. (2014). Innate immunity to influenza virus infection. Nature Reviews Immunology, 14(5), 315. doi:  10.1038/nri3665.

Jefferies, S., Braithwaite, I., Walker, S., Weatherall, M., Jennings, L., Luck, M., … & Perrin, K. (2016). Randomized controlled trial of the effect of regular paracetamol on influenza infection. Respirology, 21(2), 370-377. https://doi.org/10.1111/resp.12685

Lionakis, N., Mendrinos, D., Sanidas, E., Favatas, G., & Georgopoulou, M. (2012). Hypertension in the elderly. World journal of cardiology, 4(5), 135. doi:  10.4330/wjc.v4.i5.135

Weber, M. A., Schiffrin, E. L., White, W. B., Mann, S., Lindholm, L. H., Kenerson, J. G., … & Cohen, D. L. (2014). Clinical practice guidelines for the management of hypertension in the community. The journal of clinical hypertension, 16(1), 14-26.DOI:10.1097/HJH.0000000000000065