THE HOLIDAYS AND PNEUMONIA

The holiday season is upon us which means in the nursing home so are the viruses and bacterial respiratory infections. The bugs are going through the facilities like wild fires and affecting just about everybody, including the staff, in various forms. The healthy staff has had upper respiratory infections which consisted of the usual cough, congestion, sinus pressure, sore throat, and low grade fever. They feel lousy for a few days and are able to come back to work without any problems. This is usually viral and treatment is for symptoms only. The staff that decided to work while ill spread their bug to others including the frail elderly population that resides in the long-term care facility. Many of the staff does not feel like going to work but feel pressured by their supervisor(s) because they do not have sick hours or the facility is short staffed and they do not want to use registry. It is basically a money motivator instead of the welfare for their residents. I personally believe the director of nursing should take the responsibility to keep their sick staff away from the facility until they can no longer spread their bugs. But unfortunately that does not happen. What scares me is it is early in the season and the flu virus peak season starts in February. And the cycle begins.

Mrs. M was lying in her bed when I arrived at the facility. The nurse reported she did not eat breakfast and did not want to get dressed today. Yesterday she ate most of her meals but it was not her usual >70% consumption for each meal depending if she liked it or not. Mrs. M also had dementia which made her a poor historian.

“Mrs. M did not eat today? What are her vital signs?” I asked Ruth, the LPN on day shift.

“They are fine. Her temperature is 98.7. She has had a cough over the past couple of days,” replied Ruth. 

“What do her lungs sound like?” I asked.

“They sounded okay to me but she won’t take a deep breath so it is hard to hear,” said Ruth. I knew this was true because Mrs. M usually did not follow direction.

“What is her normal temperature?” I asked Ruth. Ruth flipped through the chart.

“Her normal temperature is around 96.8,” said Ruth as she pointed to the boxes with Mrs. M’s temperatures for the month.

“It sounds like she has a little temp. I need to examine her. Is she in her room?” I asked.

“Yes. She does not want to get out of bed today. That is very unlike her,” said Ruth in a concerned voice. I grabbed some alcohol wipes and used the bacteriostatic gel on my hands before going into Mrs. M’s room.

I walked down the hallway and saw Mrs. M’s door closed. I lightly knocked and opened the door seeing the CNA was just finishing changing Mrs. M when I arrived. I wiped down my stethoscope with an alcohol wipe.

“How is she doing?” I asked the CNA.

“She does not want to do much. I think she is sick or something,” said the CNA as she grabbed the soiled brief with her gloved hand to throw away.

I looked at Mrs. M while she was trying to sleep in her bed. She looked slightly flush in the dim light. Mrs. M did not look like her usual happy self. I could tell she was not feeling well. I felt her forehead with the back of my right hand. She felt warmer than 98.7. The CNA was in the bathroom.

“Could you please get the thermometer and re-check her temperature and her pulse oximetry?” I asked.

“Ok,” said the CNA as she finished in the bathroom getting rid of the soiled brief.

I examined Mrs. M. She would not deep breath for me which was not unusual. She was more fatigued than normal and did not want me bothering her. She wanted to sleep. The CNA checked her temperature and it was 99.6. What concerned me was Mrs. M was not eating or drinking and could get dehydrated very easily for her small 104 pound frame. Her pulse oximetry was 91%. Mrs. M had no medical history of respiratory problems. 

I walked down the hallway to the nurse’s station where Ruth was sitting at the table. I grabbed an order sheet and wrote STAT CBC, CXR, BMP, Albuterol SVN’s every 4 hours x 2 days, Tylenol for fever. I looked in the chart and saw Mrs. M had an allergy to codeine. I had the feeling Mrs. M had pneumonia and wanted to get a jump on her treatment. The results would be back within 5 hours.

The results came back showing her WBC was 14.4 and her CXR showed bibasilar infiltrates indicating pneumonia. An order for IM Rocephin 1 gram was written to get a start on the pneumonia. I talked to her family about the diagnosis and asked if their mother did not drink did they want IV fluids. They decided yes they would because it would help their 92-year-old mother. So far Mrs. M was taking in a little fluid but we needed to monitor it because she could decline fast. Mrs. M was taking her medications. Doxycycline 100mg BID was ordered. One of the organisms in the long-term care facilities is MRSA which many of the common antibiotics do not cover. Doxycycline does and I have used it frequently for my patients with pneumonia.

Mrs. M did recover and did not need IV fluids for hydration. Unfortunately some of the residents in the long-term care facilities have needed IV fluids and antibiotics and still did not do well. Pneumonia is one of the top killers in the elderly population. I lost two last week to the infection while they were in the hospital. Pneumonia is one of the top killers in the elderly population which could start as a simple viral respiratory infection. The frail elderly do not have strong immune systems and normally do not drink a lot of fluids even though they think they do. They become dehydrated very rapidly. Another problem with the frail elderly is they like to sleep most of the day and stay in bed unless taken by the CNA’s to another location besides their rooms. They cannot force the resident to go to activities but they can persuade them and give them the reasons why it would be beneficial. The elderly in the long-term care facilities do not take deep breaths to expand their lungs on a regular basis which can cause atelectasis. If the resident has any respiratory diseases such as asthma or COPD this also increases their risk of developing pneumonia. All of these factors can contribute to a poor outcome.

It is early in the season and already I have seen several cases of pneumonia in my patient population. I have learned I need to get a jump start if the staff or I see any change in condition. Unfortunately the patient can look well one day and be terribly ill the next. Yes, it is going to be a long first winter season for me as a nurse practitioner.