Question

Case Study, Chapter 23, Management of Patients with Chest and Respiratory Tract Disorders DIN CAPSA 1. Harry Smith, 70 years of age, is a male patient who is admitted to the unit with acute community-acquired pneumonia. He was dingnosed with paris emphysema 3 years ago. The patient smoked cigarettes one pack per day quit 3 years ago. The patient has a history of hypertension and diabetes control itted to the medical-surgical nosed with paraseptal per day for 55 years and with ion as to time and place. The family sion vital signs are as follows: 101 bpm, testis 85% stated that this is a new change for the patient. The admission vital signs are as blood pressure 90/S0 mm He heart rate 101 bom respiratory rate 28 breaths/min, a temperature 101.5°F The pulse oximeter on room air is 85% The CBC is as follow WBC 12.500, platelets 350,000, HCT 30% and Hob 10 L. ABGs on room air 7.30, Pao, 55, Paco, 50, HCO, 25. Chest x-ray results reveal right lower lobe consolidation, presence of apical bullae, flattened diaphragm, and a small pleural 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 o 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 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 NANDA 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? 2. Marie Perez, a 53-year-old patient, is day 1 after a gastric bypass. She complains of shortness of breath; her respiratory rate is 30 breaths/min, heart rate is 110 bpm, pulse oximetry 89% on room air, temperature is 100°F, and her blood pressure is 90/50 mm Hg. She complains of feeling anxious and having stabbing chest pain which gets worse with inspiration. She complains that she feels like she is going to pass out or possibly die. (Learning Objective 7) a. What could possibly be going on with the patient and what measures should the nurse provide immediately?

Answer 1

a.The following nursing assessment findings which support the diagnosis of pneumonia are

• Fever
• Fatigue
• Shortness of breath, tachhpnea,cough, dimnished Barth sounds in right lower lobe,absent breath sounds at base
• Tachycardia
• Diaphoresis

b.The following diagnostic findings support the diagnosis of pneumonia are

• Chest X ray
• ABG :Decreased oxygen and increased carbondioxide (Acute uncompensated primary respiratory acidosis )

c.The nanda diagnosis for this patient is

• Ineffective breathing pattern /Impaired gas exchange related to consolidation as evidenced by dyspnea, hypoxia,tachhpnea,

d.The following goals has to be developed for this patient

• To reduce fever to normal temperature
• To maintain oxygen saturation above 90%
• To treat infection for consolidation with antibiotics as prescribed

e.The overall intervention to be done are

• Administration of oxygen
• Monitoring vital sings
• Administration of medication
• Teaching breathing exercise
• Assessing for any signs of complications