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. Your assessment findings are as follows: Mr. Kline's vital signs are B/P 154/82, P. 105, R. 32, and T. 103 F. on room air. 02 sats on room air are 84%. You auscultate decreased breath sounds in the LLL interiorly and posteriorly, course crackles LUL. His nail beds are dusky on fingers and toes. He has a cough productive of rust-colored sputum and complains of pain in his left chest when he coughs. Mr. Kline appears to be well nourished and adequately well hydrated. He is a lifetime non-smoker, non-drinker. Past medical history CAD/MI X 2/stent X 3. On metropolol, amiodipine, Lisinopril, furosemide, type 2 diabetes mellitus on metformin and roliglitazone. He reports that he has not been sexually active for 15 years but was always monogamous with his wife of 49 years. He has never gotten a flu or the Pneumovax vaccines. He does report getting hives when he took an antibiotic pill a few years ago but does not remember the name of the antibiotic

Answer 1

Pneumonia

Nursing Diagnosis Ineffective breathing pattern related to poor has exchange as evidenced by tachypnea, cough,secretion,dusky nails beds,crackles in lungs	Altered body temperature related to infection as evidenced by r as ise in body temperature secondary to pneumonia
Intervention Monitor vital signs ,baseline to plan for care Administer oxygen via nasal cannula to treat hypoxia Provide propped up position, to enhance lung capacity and breathing Administer antibiotics to treat the underlying infection Monitor ABG to assess acid base imbalance	Monitor vital signs, baseline to plan for care Administer antipyretics to reduce fever Encourage fluid intake this can decrease the body temperature Provide rapid sponge to cool down the skin Treat infection
Positive outcome The patient will be able to breath easily	The patient will have a normal body temperature
Negative outcome Risk of developing complications due to other medical condition Side effects of treatment expected	A very high temperature could have damaged the internal organ function
Evaluation Normal breath pattern can be observed	Normothermic on evaluation