Case Study, Chapter 23, Management of Patient with Chest and Lower Respiratory Tract Disorder
You are directed in the instructions to include the case study… please remember this in the future.
What nursing assessment findings support the diagnosis of pneumonia?
Base on the information presented in the case study the nursing assessment finding that is critical in detecting pneumonia would be fevers and chills, the patient is also experiencing diaphragmic breathing and is using accessory muscle to help with breathing. Complains of shortness of breath and unable to complete full sentences. The patient pulse oximetry reading decrease over time on room air and patient is noted with cyanosis, this will also cause the patient to experience altered metal status due to lack of oxygen being supply to the brain. Diminish breath sounds and in the right lower lobe and absence at the base indicates atelectasis which also helps to support the diagnosis. According to (Lippincott Williams and Wilkins pg. 582) Clinical manifestation of pneumonia are fatigue, tachypnea, the use of accessory muscle for breathing, coughing and purulent sputum, Although the patient in this cause does not produce any sputum, the other manifestations are signs of pneumonia further tests are done to conclude infection.
What diagnostic findings support the diagnosis of pneumonia?
Diagnosis of pneumonia is made by physical examinations, these are not diagnostic tests…
chest x-ray, blood work and sputum sample. sputum sample was not in the case study.. although yes, this would be done..
In this case CBC were done with WBC count being 12, 500, this indicate a sign of infection noting that the blood count is greater than 10,000. Another indication that the patient is experiencing an infection is the elevated temperature, the patient temperature is 101.5. The chest x-ray results revealed the right lower lobe consolidation and pleural effusion. In this case a sputum culture was not obtained. (According to Lippincott pg 582,) a sputum, can be obtained by nasotracheal or orotracheal suction if the patient is unable to cough up sputum on their own.
What nursing diagnoses should the nurse formulate for the patient?
Base on the assessment finding a few nursing diagnoses can be formulated.
this patient had many more nursing diagnoses that apply to his situation…
● Ineffective airway clearance related to secretion
● Risk for infection related to immunocompromise
● Activity intolerance related to impaired respiratory function
● Deficient knowledge about the treatment regimen and preventative measures
● Risk for fluid deficient volume the correct NANDA terminology is Imbalance fluid volume less than body requirement
● Ineffective breathing patterns
● Impaired gas exchange
● Acute confusion
● Risk for injury
● Risk of infection
● Risk of impaired skin integrity
● Risk of imbalanced nutrition less than body requirement
● Self-care deficit
● Impaired healthcare maintenance
What goals should the nurse develop for the patient?
You are stating these with rationale.. you need to state them with objective measurable terms.
Eradication of the infection
Improve airway patency to return the RR to WNL and O2 sat above 92%
Increase fluid intake to 2-3L per day with urine output WNL