Question

PN 200 Fundamentals of Nursing II Concept Map - Pneumonia The sister of Calvin Kline called to report that her 71 year-old brother came down with a fever 2 days ago. Now he has shaking chills, productive cough, inability to lie down to sleep because "He cannot stop coughing" Mr. Kline is examined at the hospital's Primary Care Clinic, and is diagnosed with community acquired pneumonia (CAP) and now is admitted to your floor. The intern is busy and asks you to complete your routine admission assessment and call him with your findings. Your assessment findings are as follows: Mr. Kline's vital signs are B/P 154/82, P. 105, R. 32, and T. 103 F. on room air. 02 sats on room air are 84%. You auscultate decreased breath sounds in the LLL interiorly and posteriorly, course crackles LUL. His nail beds are dusky on fingers and toes. He has a cough productive of rust-colored sputum and complains of pain in his left chest when he coughs. Mr. Kline appears to be well nourished and adequately well hydrated. He is a lifetime non-smoker, non-drinker. Past medical history CAD/MI X 2/stent X 3. On metropolol, amiodipine, Lisinopril, furosemide, type 2 diabetes mellitus on metformin and roliglitazone. He reports that he has not been sexually active for 15 years but was always monogamous with his wife of 49 years. He has never gotten a flu or the Pneumovax vaccines. He does report getting hives when he took an antibiotic pill a few years ago but does not remember the name of the antibiotic

Answer 1

1)Nursing Diagnosis 1: Impaired Gas exchange related to hypoventilation secondary to mucus plug in the airways evidenced by oxygen saturation of 84% on room air and pale and dusky fingers and toes

Interventions.Assess the patients respiration pattern,use of accessory muscles,depth of respiration it will help us to understand the efforts the patient takes in breathing .

Assess the patients skin color for cynosis ,irritability, consiusness level.hypoxia can lead to cynosis and loss of consiusness.

Assess the patients saturation regularly

Give head elevation and propped up position which will help in increased intra thoracic spce and thus help in gas exchange

Plan rest period in-between the activities to have a balance in oxygen demand and consumption.

Teach breathing and coughing exercise which will help in loosen secretions and maintain airway

Administer oxygen as per the requirement through nasal prongs or face mask
If needed can try non invasive ventilation.

Positive outcome :Patient will have a sstauration of 98-100 % on room air .patient is able to exercise

Adequately to help remove secretions .

Negative outcome:Patient has poor saturation,patient has blocked airway with secretions

Evaluation:At the end of 8 hrs patient has saturation of 98% on nasal prongs,at the end of 2r hrs patient can exercise independently to excrete mucous secretions .At the end of 24 hrs patient has no cynosis of extremities.

2)Nursing Diagnosis 2 : Hyperthermia related to infection as evidenced by fever of 103 degree F

Interventions :

assess the patients temperature,hydration on regular basis to get a baseline understanding.

Adminster anti pyretics to relive fever

Encourage oral fluid to prevent dehydration.

Send blood cultures and sputum cultures to assess the organism growing to start on sensitive antibiotics .

Adminster sensitive antibiotics.

Reduce the covering linnen which will help relieve Temperature

Adminster oxygen as fever increases the xygen consumption

Provide adequate rest in between activities to help hrelive malaise and weakness

Positive outcome :Patient has body temperature of 98.6 F at the end of 8 hours .

Patient doesn't have purulent secretions .patient doesn't have weakness or malaise

Negative outcome :patient has fever of 103 degree F

Patient has purulent secretions

Patient has malise and body pain

Evaluation:At the end of 24 hrs patient has body temperature of 98.6 degree F.Patient Is able to perform activities of daily living independently,patient has normal fluid volume balance ,patient has oxygen saturation of 98% on room air