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.

Answer 1

pneumonia:

Inflammertion 4 lungs caused by Baituria of viral Infection, alvedau Edema - so that air sacs are filled with pus and finally become solid - It present as couble pneumonia, where both lungs are involved a single pneumoria where one bergs are involved

Nursing diagnosis:

In Edfective airway clearance Impaired Gas Exchange Instfective Breathing pattern - Risk for Infection. > Acute pain → Activity intolerance >> HyperThermia 27 Risk for Deficient fluid volume > Risk for Inbalanced Nutrition → Deficient knowledge ondores one

Intervention;

Assess The gate, shythm, and depth of guespiration, cheske movement, and use of accessory muscles ar » Aslultati larg fields t o I observe the sputum colour, viscosity and odor - Assess The patient hydration status

Therapeutic intervention:

Therapeutic Interventions Ekvate head of bed, charge position frequently. Teach and assist patient with proper deep breathing exercise Administor medication as indicated like mucolytics, expectorants, Broncho dilat013 and analgesicos » monitog chest x.gays, pulse Oximety setting, To ' intera

positive outcomes:

patients maintain an effective breathers pattern, as evidenced by relaned breathers aut normal rate and depth and absence 4 dyspnea. → patient responentory got remains within Established limitsat patient will maintain optimal gas Exchange

Negative outcomes:

→ Bacteremia and septic shock lung absussess, Nausea, vomitting » pleural Edfusion Empyema and pleurity » Renal failur, » Respiratory failure → Urinary Tract ingection

Evaluation;

& abnormal sounds like crauding, rumbling or wheezing, cloctor can listen - chest x-ray check for white spots & lungs, - CT of the lings show the airway of Trachen and Blonchii, - ultrasound of the chest, used to suspect The fluid surronding the lungs, =) MRI the chest:- » Needle biopsy of lung to cetermine the cause of pneumonia.