Bacterial Pneumonia

[mkapulelauriano]

I have a case study that I can not figure out. Any feedback would be greatly appreciated.

84yo received at the clinic with her caregiver who reports she has a one week hx of upper respiratory symptoms and a day hx of increasing weakness and malaise. three days ago developed a cough that gradually became with worse with SOB. thick green phlegm.

PMH: tobacco dependence x 64 yrs, chronic bronchitis x 13 yrs, HTN x 6yrs controlled with BP meds. VS 140/80, 95, 38, 98.3. O2 sat 80% ra.

PE: skin: warm, clammy. HEENT: Nares slightly flared. purulent discharge visible, pharynx erythematous with purulent post-nasal drainage. mucous membranes inflamed and moist. LUNGS: RUL and LUL crackles and diminished breath sounds, RLL and LLL absence of breath sounds and dullness to percussion

Abnormal LABS: glucose: 138mg/dl, WBC 15,200/mm3, Neutros 82%, Lymphs 10%

QUESTION: Why does this patient NOT have a fever??? I always thought a fever was the first indication of an immune response to an infection?

[edgwow]

First I thought of, What level of care are they in Med surge or ICU, are they getting IV antibiotics, if not , I think they should be to address the the crackles usually indicative of pneumonia. What does the chest x ray show, was infectious diseases consulted, sputum culture or nasal pharnyx washing sent? I am sure that with a sat of 80 the patient is getting oxygen, but with someone who has chronic lung disease, as you would with the extensive smoking and bronchitis history, they may routinely pulsox 85-89% and not be in acute respiratory distress. Those folks live with these low pulsoxes everyday, its just that no one is actually checking their pulsox every day when they are home. Were blood cultures done? Where is this patients CO2 by abg or even blood metabolic panel? 15,000WBC's are elevated but many, many people do not develop fevers until thier WBCs are over 20 or higher.They may take herbal supplements to boost their immunity, be well hydrated,and not yet exhibiting a fever. The other concern is are there actually no breath sounds on the one side possible requiring the need for a chest tube? This is probably not exactly what you were looking for but absolutely pertinent questions given the case study details described.

[nurseladybug12]

Is she being immunosuppressed in any way? I think if she is on a steroid or chemo she may not have a fever even with infection going on.

[nurseladybug12]

Or she even could have a temp that is below normal instead of a fever.

[Esme12, ASN, BSN, RN]

Welcome to AN! The largest online nurswing community!

Is this patient septic? Does this patients age have any impact on his ability to reflect an elevated temp?