Appropriate order for diabetic + COPD + pneumonia?

*4!#6 · Apr 16, 2012

I would think that the pt probably has a lot of secretions with the pneumonia, and probably difficulty breathing. The steriods will help the patient breath and remain oxygenated as well as clear the secretions from his lungs and prevent worsening infections. I wonder if a more short-term course of steriods would not decrease the immune system or would not have some more of the severe long term effects. I think the priorities for htis patient would be to help him remain oxygenated and clear his infection, so the steriods would be indicated. Not sure for the IV insulin unless his sugars are all over the place? I would watch the BG very carefully because I think you're right in the HHNS thinking. I know infections are a huge trigger for this in the elderly.

I am glad you asked this quesiton, I am learning a lot from reading these posts :)

wooh, BSN, RN · Apr 16, 2012

All the worries about steroids effects on the immune system are one of those classic overthinking things. Which as a student, I had a ton of trouble with, particularly with steroids, as you never know when you need to think more and when you've gone too far, as that tends to fall more under the "art" of nursing and medicine rather than the "science." :)

A very simplistic general rule of thumb for steroids and when to worry about immune responses is: Acute care go for the steroids! They'll help you get better before the immune suppression really hits its stride. The worries about immune suppression tend to be when you're on them long term.

And you nailed it with the nursing school answer of "airway has priority over infection." You can treat an infection if they're still breathing.

Pulmonary hygiene is super important with pneumonia. You want them moving around. Loosening up the crud that's in their lungs. Breathing deeply, incentive spirometer, turn/cough/deep breathe, that good stuff that gets oxygen down into the farthest reaches of the lungs.

This person needs to be in ICU for careful monitoring of respiratory and metabolic status.

Wow, that would be nice. Back when I still did adults, that was a typical floor patient. It was rare to have a patient without a history of COPD and DM. :)

mindlor · Apr 16, 2012

With all due respect, are you in nursing school or med school?

Why not let the doctors do the doctoring and you do the nursing.

I see way too many of my fellow students get stuck in the patho weeds..

KatePasa · Apr 16, 2012

That's hilarious! I'll make sure my instructors, the writers of the NCLEX and the BON know that I don't need to know about disease processes and why a medication would be selected to treat them. I just hope to see an option for "because the doctor says so" on my exams, NCLEX, and in my future as a nurse in general.

Esme12, ASN, BSN, RN · Apr 16, 2012

In order for us to help you we need all the information. What you have done, Where it has lead you, and Where you left off. Many come here wanting their homework answered for them and I want to know where you are so I can lead you in the best direction. Are you a first year in the beginning and not knowing A from B or are you more advanced into the pathophysiology.

The CAP exacerbates the COPD and lung inflammation that accompanies CAP. Steroid IV are used with CAP if the patients are severe enough dyspnea/wheezing is present. The immune response suppression is a consideration but not an implication to not use the IV steroids when the benefit far exceeds the risk......especially in short term/acute use.

Use of Corticosteroids in Treatment of COPD

Short courses of corticosteroids have conclusively been shown to improve both spirometric and clinical outcomes in acute exacerbations of COPD.

Medscape: Medscape Access you have to register but it is free...no strings and an excellent reference!

There are many here on AN that love to be provocative for the sake of argument....it's all good!

KatePasa · Apr 16, 2012

I understand the patho of COPD, which I would go into ad nauseum, but for the sake of brevity I'll just say destuction of alveoli, excessive secretions, dyspnea, and chronic high CO2 levels. I understand that inhaled and oral corticosteroids are beneficial short term, but in some cases may be a contributing factor to exacerbations and pneumonia.

I am a first year student in Med Surg I. This is my first encounter with a systemic steroid. However, I would say that I am advanced in pathophysiology and understand the underlying cycles of inflammation and infection that occur with COPD. This is a simulation patient, so I haven't done anything with him except read his case study and look over his meds and labs. He's on Advair (fluticasone + salmeterol = a corticosteroid + a long acting bronchodialator) already, which might have contributed to the pneumonia. The fellow doesn't have a SABA med listed.

While I know inhaled corticosteroids treat exacerbations of COPD, pneumonia is distinct from an exacerbation in that it has a rapid onset (as compared to the exacerbations which may develop over a greater span of time). I suppose that is the rationale behind the systemic steroid...acute problem, treat it system-wide? prevent bacteremia?

In terms of where we are as a class with regard to Med Surg, we've been dealing with chronic problems, diabetes and COPD. Hence the patient with diabetes and COPD for simulation! We have not delved into acute care, so that's still a bit mysterious to me. We have two eight week "semesters", so we are midterm right now.

I've got a strong knowledge base, which is probably my greatest attribute when it comes to nursing school. I do realize that the brevity and lack of background of my original post did make me sound like a moocher!

KatePasa · Apr 16, 2012

And thank you for the Medscape suggestion. I am a subscriber, and I'll go poke around.

KatePasa · Apr 16, 2012

All the worries about steroids effects on the immune system are one of those classic overthinking things. Which as a student, I had a ton of trouble with, particularly with steroids, as you never know when you need to think more and when you've gone too far, as that tends to fall more under the "art" of nursing and medicine rather than the "science." :)
A very simplistic general rule of thumb for steroids and when to worry about immune responses is: Acute care go for the steroids! They'll help you get better before the immune suppression really hits its stride. The worries about immune suppression tend to be when you're on them long term.
And you nailed it with the nursing school answer of "airway has priority over infection." You can treat an infection if they're still breathing.
Pulmonary hygiene is super important with pneumonia. You want them moving around. Loosening up the crud that's in their lungs. Breathing deeply, incentive spirometer, turn/cough/deep breathe, that good stuff that gets oxygen down into the farthest reaches of the lungs.
Wow, that would be nice. Back when I still did adults, that was a typical floor patient. It was rare to have a patient without a history of COPD and DM. :)

Thank you for this response. Not only have you pegged me, you helped me realize the point to the situation. Desperate times call for desperate measures (e.g. systemic steroids).

nurseprnRN, BSN, RN · Apr 16, 2012

don't let anybody dissuade you from learning pathophysiology. the nurses who make the excuse that "the doctor knows all that, he'll take care of it," are, in my opinion, incurious at least, and lazy at worst. there is absolutely no reason to believe that this level of understanding is either wasted in obtaining a good nursing education or limited to the physician's guild. you just keep right on asking, and learning. i love this physiology stuff and if i hadn't been away all weekend i might have chimed in earlier. as a nurse i have used it extensively for most of my nursing career, in many different clinical and nonclinical settings.

somebody mentioned lots of iv steroids in neurosurg. i believe that the hope that a good whopping dose of methylprednisolone (solu-medrol) for acute sci has been dashed in the light of further data. it does not seem to improve outcomes in terms of spinal function. however, you see dexamethasone (decadron) a lot in stroke, tbi, and other edema-causing brain problems, and in spinal surgery, because it decreases edema. when i had my back surgery, decadron was my best friend...to a point. it also messes with the blood sugar, so be careful to watch diabetics or prediabetics very carefully, and for people who have ongoing music in their heads it makes it louder and more persistent. i could hardly sleep for the racket. really.

mindlor · Apr 17, 2012

Ya know what, I have classmates failing out of school because they are brilliant with the path and dont know a hoot about nursing interventions........a foundational knowledge of patho is of course required.......but to get down to nth degree is simply not required and is in fact, based on my limited experience, detrimental to students.......

Of course if you know patho to the nth degree and you know the nursing stuff as well, then you ROCK :)

KatePasa · Apr 17, 2012

Mindlor, I am a notorious know-it-all to the nth degree!

JustBeachyNurse, LPN · Apr 17, 2012

Kate, I think your willingness to learn the pathophysiology as a means to predict and understand the medical and nursing interventions is admirable. You seem to really have a grasp on the disease process and I can understand your initial confusion going from basic chronic conditions to acute exacerbations. But your persistence to understand the thought process seems to have paid off and you should do great with your sim patient. Understanding the why of the treatment and disease process not only helps you comprehend the wholistic picture but I think it puts you at an advantage for patient education...as long as we can all remember to present the information at the patient's level of understanding.