Nursing Care of a Patient Diagnosed with Pneumonia
Nursing Care of a Patient Diagnosed with Pneumonia
Tiara Graham
Linn Benton Community College
Nursing Care of a Patient Diagnosed with Pneumonia
Patient Description Patient is a Caucasian 83 year old female that came into the emergency department from Wynwood assisted living facility with an increase of fatigue, worsening confusion and a 1 day history of a fever. Patient weighs approximately 90 pounds upon admission with a height of 64 inches. Patient has known COPD and is a former heavy smoker that also has a history of pneumonia, hypertension, atrial fibrillation, and dementia. Upon presentation to the emergency department patient has had increased nasal drainage and cough. Patient came into the hospital about a year and a half ago with a diagnosis of right lower lobe pneumonia. Patient was arousable, alert and pleasant, but not a good historian and appears to be quite emaciated. Patient at first had a non productive cough and was put on anti-biotics and began to have a productive cough 2 days post admission. Patient had dyspnea, increase respiration rate, difficulty talking, coarse lungs, and had decreased SpO2 with activity. Patient lived in Wynwood assisted living facility where she lived almost independently. Patient was able to get around her apartment with a front wheel walker and provided her own care of activities of daily living. With this admission, hospital staff did not recommend patient going back to assisted living as she would not be able to take care of her self until her mobility is back to her normal limits and the dyspnea is decreased.
Nursing Diagnosis
Ineffective airway clearance r/t bronchospasm, excessive mucous production, tenacious secretions, fatigue AMB dyspnea, increase RR (28), difficulty talking, inability to raise secretions, ineffective cough, adventitious breath sounds.
Goals
A. Pt will demonstrate effective coughing and clear breath sounds by end of shift 5/15/10 (3 days) and until discharge.
B. Pt will
Tiara Graham
Linn Benton Community College
Nursing Care of a Patient Diagnosed with Pneumonia
Patient Description Patient is a Caucasian 83 year old female that came into the emergency department from Wynwood assisted living facility with an increase of fatigue, worsening confusion and a 1 day history of a fever. Patient weighs approximately 90 pounds upon admission with a height of 64 inches. Patient has known COPD and is a former heavy smoker that also has a history of pneumonia, hypertension, atrial fibrillation, and dementia. Upon presentation to the emergency department patient has had increased nasal drainage and cough. Patient came into the hospital about a year and a half ago with a diagnosis of right lower lobe pneumonia. Patient was arousable, alert and pleasant, but not a good historian and appears to be quite emaciated. Patient at first had a non productive cough and was put on anti-biotics and began to have a productive cough 2 days post admission. Patient had dyspnea, increase respiration rate, difficulty talking, coarse lungs, and had decreased SpO2 with activity. Patient lived in Wynwood assisted living facility where she lived almost independently. Patient was able to get around her apartment with a front wheel walker and provided her own care of activities of daily living. With this admission, hospital staff did not recommend patient going back to assisted living as she would not be able to take care of her self until her mobility is back to her normal limits and the dyspnea is decreased.
Nursing Diagnosis
Ineffective airway clearance r/t bronchospasm, excessive mucous production, tenacious secretions, fatigue AMB dyspnea, increase RR (28), difficulty talking, inability to raise secretions, ineffective cough, adventitious breath sounds.
Goals
A. Pt will demonstrate effective coughing and clear breath sounds by end of shift 5/15/10 (3 days) and until discharge.
B. Pt will
References: Sanford, J.T. & Jacobs, M. (2008). Impaired gas exchange. In B.J. Ackley & G.B. Ladwig (Eds.) Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed., pp. 388-390). St Louis, MO: Elsevier. Sanford, J.T. & Jacobs, M. (2008). Ineffective airway clearance. In B.J. Ackley & G.B. Ladwig (Eds.) Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed., pp. 124-129). St Louis, MO: Elsevier. Simpson, H. (2006). Respiratory assessment. British Journal of Nursing (BJN), 15(9), 484-488. Retrieved from CINAHL with full text database.