Question

The nurse is caring for a frail, older patient in the hospital after surgery to repair a bowel obstruction. The patient has a nasogastric NG tube, through which all her scheduled drugs are given, oxygen at 1 liter/nasal cannula at night, an indwelling urinary caterer, and a saline lock. The patient is weak and fatigued, has pain not relieved by IV opioids, and is reluctant to participate in any activities.

What risk factors does this patient have for developing pneumonia?

What actions does the nurse take to decrease the patient’s risk for pneumonia?

Two days later, the NG tube is removed and the patient is started on ice chips and other clear liquids. The patient swallows repeatedly when given sips of water. What action does the nurse perform?

The nurse does hourly rounds on the patient, and the patient’s daughter states, “Something is just not right with mom” What action should the nurse take first? What other actions should the nurse perform?

The physician orders a chest x-ray, and the results show pneumonia. What actions by the nurse are most important?

Answer 1

●The main risk factor for getting pneumonia is lack of activities because post surgery the lung functions has to be restored back by using a Spirometry.Lack of activity can leads to developing of secretion on the lungs ,causing infection.

●The nurse can reduce the risk of pneumonia by

• Making her use Spirometry every second hourly
• Propped up position
• Suctioning in case of secretions
• Administration of antibiotic as per order
• Following a strict hand hygiene and asepsis in the procedures
• Breathing exercises

●The nurse should assess for any swallowing problem to check out the return of Muscle refraction.When this fails patient has no control while swallowing.This can also be a cause of loss of reflex in the tongue The nurse should ask the patient to hold the water for few seconds and then gulp it down

●The immediate action to be taken is checking patients vitals (TPR,BP,SPO2), observation of surgical site for any bleeding ,pain,oozing etc., Assess the patients psychological status to check mental soundness by calling out name ,etc.,

The other actions to be done is to inform the concerned physicians using SOAP and follow the orders.Documentation of the patiwnt status in beprief at last

●The following actions of the nurse are most important

• Monitor the vital signs
• Hand hygiene
• Infection control practice
• to maintain a proper diet and nutrition required for the patient to prevent dehydration and malnutrition
• Teach patient cough etiquette