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Nursing Management
THE PATIENT WITH PNEUMONIA
ASSESSMENT
Health
History:
Alice Guthrie 77 years old, is a retired school teacher who complains of chills
and fever cough sore throat and chest pain the physician diagnoses pneumonia
and recommended hospitalization. Ms. Guthrie states she had a cold for about a
week and seemed to get progressively worse she states she has “a little”
shortness of breath and tires very of breath and tires very easily. Her chest
pain is aggravated by coughing she has been taking over-the counter cold
remedies. She has a history of hypertension and congestive heart failure for
which for which she takes verapamil hydrocloride (calan Sr, 240 mg daily, and
digoxin, 0,25 mg daily Ms. Guthrie lives alone in a one-story apartment. She
has a close friend next door who visits frequently.
Physical
Examination:
Vital signs: temperature, 100.6 F orally pulse, 92, respiration, 24; blood
pressure 160/94. Alert slightly dyspnea skin color pale, nail beds slightly
dusky Lung sounds clear to ausculation over right lung fields wheezes and
crakles ausculated in left lung. Frequent cough producing greenish sputum No
retractions or use of accessory muscles of respiration. Abdomen soft.
GOALS
AND OUTCOME
NURSING
DIAGNOSIS - CRITERIA - INTERVENTIONS
Ineffective
airway clearance related to increased sputum production, and thick secretions.
The patient will have a patient airway as evidenced by clear breath sounds
without wheezes or crakles. Administer antimicrobials, decongestants, and
expectorants as ordered. Administer antitussives as ordered if cough interferes
with rest. Suction only if necessary. Turn, deep breathe, and cough at least
every 2 hours, perform chest physiotherapy and provide aerosol therapy as
ordered. Assess response. Monitor lung sounds, respiratory rate, and
characteristics of secretions. Dispose of tissues in a sanitary manner.
Impaired
gas exchange related to obstruction of airways by edema and secretions or
atelectasis. The patient will have adequate oxygenation as evidenced by normal
arterial blood gases and vital signs. Monitor vital signs, lung sounds, skin
color gas reports and level of consciousness. Be alert for signs of hypoxemia:
restlessness, tachycardia, tachypnea Report abdominal findings to physician.
Elevate head of bed. Administer oxygen therapy as ordered.
Activity
intolerance related to fatigue or hypoxia. The patient will demonstrate
activities of daily living without excessive fatigue or dyspnea instruct in
activity restrictions as ordered. Plan care to allow periods of uninterrupted
rest. Assist with activities of saily living as needed. Gradually encourage
increased activity while monitoring for dyspnea and fatigue. Keep interactions
short, and limit visitors.
Altered
nutrition: less than body requirements related to anorexia dyspnea or fatigue.
The patient will maintain optimal nutritional status as evidenced by stable
body weight. Monitor food intake and weight if intake is poor, consult with
dietitian about patient preferences suggest small, frequent meals position for
comfort. Use oxygen cannula during meals if permitted. Weight daily.
High
risk for fluid volume deficit related to inadequate fluid intake, fever or
mouth breathing. The patient’s hydration will remain normal as evidenced by
fluid intake equal to output, moist mucous membranes, and blood pressure
consistent with patient’s norms. Monitor fluid status for signs of fluid volume
deficit decreased skin turgor, concentrated urine, decreased urine output, dry
mucous membranes, elevated hemoglobin and hematocrit levels. Administer
intravenous fluids as ordered. Encourage fluids by mouth up to 3 liters daily
unless contraindicated. Record intake and output monitor temperature and treat
fever as ordered. Keep dry and lightly covered. Administer tepid
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