Question

_{Patient Background RP is a year-old male who was admitted to the hospital from his long-term care facility afer work of dyspnea and cough. He was seen by a staff physician at the long-term care facility and was diagnosed with a COPD exacerbatice. He was scribed ar wy , but has ove r days of this Hela history of dyslipidemia, COPD, liecinhos, HTN He tely takes platum and futween w hat havice is Roy chisch sometimes productive and spea (worse than beine) Vitals T-10LT Heart 99 pm 1006 Blood Owy Physical exam c an • General elderly male, looks older than stated age • HEENT: mildly icteric, pupils equally sound and reactive to light and accommodation • Neck: supple • Resp course breath sounds, rhonchi and where heard throughout • Card: regular rate and rhythm, to murmurs, rubs, gallops • And: slightly distended • Ext modem • Skin: corted otherwise normal • Neure slightly altered, but baseline Labs Na: 141 K:42 CL9 Bicarh23 BUN: 24 Creatinine: 1.6 WEC: 19.6 Hgh: 10.8 Het: 162 Platelets: 115 Radiology Chest X-ray showed focal consolidation in the right lower lobe, suggestive of pneumonia Microbiology • Bol Negrowth the ented this erg • • Gram Stain: 4 ous epithelial cells, 4 s Cu Negrowth 48h Pneumococcal Urinary Antigen Positive Legionella Urinary Antigen: Negative Diagnosis Upomision, RP was initially given the broad spectrum s pieci wychowcHCAP Alth with a positive cul otte was deccocerie completed}

I want a student care plan for this case

and assessment for hospital care plan,please.

Answer 1

PNEUMONIA NURSING CARE PLAN

ASSESSMENT	DIAGNISIS	PATIENT GOALS	INTERVENTION:RATIONALE	IMPLEMENTATION (YES/NO)	EVALUATION OUTCOME
Subjective Data: It's difficult to breathe as complainted by the patient. Objective Date: Diminished and adventitious breathe sounds Difficult in breathre Fever Chills Cough Dyspnea VS taken as follows T:101.2 F HR: 89 bpm RR:18 bpm BP:140/86 Oxygen saturation: 84% on room air 98% on nasal cannula	impaired gas exchange related to decreased lung surface availability AEB SOB and shallow breathing. Ineffective thermoregulation related to infection AEB febrile body response Impaired tissue integrityrelated to decreased oxygen capabilityAEB decreased O2	Maintain oxygen level and effective breathing pattern Follow antibiotic plan and administration exactly as prescribed Prevent the spread of infection	Monitor oxygen saturation with pulse ox/may be blood gas if needed. Encourage coughing and cleaning air way.Administer O2 if needed. Obtain all cultures prior to administration of antibiotics . then administer them on time. Educate the patient on hand hygiene, covering their cough staying away from other sick people	Yes Yes Yes	Oxygen Saturation maintainance. Skin nfr/pwd Decrease in infection s/sx Verbal feedback and physical demonstration.