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. O2 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 2. Which of these assessment findings concerns you? (State what each symptom represents) 3. What do the abbreviations CAD and MI mean? 4. Why would each of the medications listed would be prescribed for this patient (state the action of each medication listed)?

Answer 1

2) Hives after taking antibiotics- indicates allergic reaction, so sensitivity test should be done before administration of any antibiotic.

Also high temperature, course crackles and decreased breath sounds indicates pneumonia.

3) CAD means coronary artery disease

MI means myocardial infarction

4) Metoprolol, Lisinopril and amlodipine are Antihypertensive drugs.

furosemide is loop diuretic given to prevent edema is patients with heart failure

Metformin and Roliglitazon are antidiabetic drugs

Nursing diagnosis

1) Impaired gas exchange related to retained secretions as manifested by decreased oxygen saturation.

- bed rest

- Fowler's position to increase lung expansion by desend of diaphragm which facilitates breathing

-Administration of oxygen

Outcome

Increased saturation

2) Acute pain related to frequent coughing

- Provide diversional therapy

- Provide comfort measures

- Assist in chest splinting

- Administer analgesic

Outcome

patient will be more comfortable with reduced pain.