Question

Case Study, Chapter 23, Management of Patients With Chest and Lower Respiratory Tract Disorders 1. Harry Smith, 70 years of age, is a male patient who is admitted to the medical-surgical unit with acute community-acquired pneumonia. He was diagnosed with paraseptal emphysema 3 years ago. The patient smoked cigarettes one pack per day for 55 years and quit 3 years ago. The patient has a history of hypertension, and diabetes controlled with oral diabetic agents. The patient presents with confusion as to time and place. The family stated that this is a new change for the patient. The admission vital signs are as follows: blood pressure 90/50 mm Hg, heart rate 101 bpm, respiratory rate 28 breaths/min, and temperature 101.5°F. The pulse oximeter on room air is 85%. The CBC is as follows: WBC 12,500, platelets 350.000. HCT 30%, and Hgb 10 g/dL. ABGs on room air are pH 7.30. PaO2 55, PaCO2 50, НСОз 25. Chest x-ray results reveal right lower lobe consolidation, presence of apical bullae, flattened diaphragm, and a small pleural effusion in the right lower lobe. Lung auscultation reveals severely diminished breath sounds in the right lower lobe and absence of breath sounds at the base. The breath sounds in the rest of the lungs are slightly decreased. The patient complains of fatigue and shortness of breath and cannot finish a short sentence before the respiratory rate increases above the baseline and his nail beds and lips turn a bluish tinge and the pulse oximetry decreases to 82%. The patient is diaphoretic and is using accessory muscles. The patient coughs weakly, but he does not raise any sputum. (Learning Objective 3) a. What nursing assessment findings support the diagnosis of pneumonia? b. What diagnostic findings support the diagnosis of pneumonia? c. What nursing diagnoses should the nurse formulate for the patient? d. What goals should the nurse develop for the patient? e. What overall interventions should the nurse provide?

Answer 1

a. What nursing assessment findings support the diagnosis of pneumonia?

Solution:

The assessment findings that support the diagnosis of pneumonia include fever, diaphoresis, complaint of fatigue and shortness of breath, and inability to complete a short sentence before having an increase in respirations above the baseline, which is already tachypneic, anda decrease in the pulse oximetry and development of cyanosis. The tachycardia and presence of atelectasis also support the diagnosis. Altered mental status changes in the elderly patient are seen with patients with an infection.

b. What diagnostic findings support the diagnosis of pneumonia?

Solution: Diagnosis of pneumonia performed the tests are:

Blood tests

Chest X-ray

Pulse oximetry

Sputum test

c. What nursing diagnoses should the nurse formulate for the patient?

Solution:

Nurse formulate for the patient is PES

P-stands for problem

E-stands for etiology

S-stands for signs and symptoms of problem

d. What goals should the nurse develop for the patient?

Solution:

providing quality patient care

Educating patients and families

promoting a safe environment

e. What overall interventions should the nurse provide?

Solution:

Nurse provide interventions are:

fever

low blood pressure

Normal heart rate

Normal respiratory rate

Abnormal WBC

Low HCT values

Low haemoglobin levels

Chest x-ray results reveal right lower lobe consolidation

presence of apical bullae, flattened diaphragm, and a small pleural effusion in the right lower lobe.