Question

Write one Nursing Care Plan from each of the case studies: either case study 1 or case study 2 your choice. Total 9 NCPs Submit each NCP in an individual email. Use essay format to write your NCP using this grading rubric. Objective: the student will demonstrate gained knowledge of the disease process and apply it using critical thinking skills to the specific data in the case study The rubric you will be grade by is: PNUEMONLA Medical Diagnosis 1) Definition of medical diagnosis Etiology/pathophysiology 2) Common sign/symptoms 3) Potential complications 10 4) Expected assessment findings Head to toe assessment 5) Diagnostic studies/labs values Normal Expected abnormalities 10 6) All NANDA Nursing Diagnoses 7) Develop 3 NANDA Priority Nursing diagnosis 8) State patient goals/plan 10 10 nursing diagnosis 10 9) Write interventions for your plan 10) Scientific rationale for interventions 11) Write how you would evaluate your plan

Answer 1

Pneumonia is an infection of one orr both lungs caused by bacteria, viruses, fungi or parasites. this condition is medicaly diagnosed on the basis of signs and symptoms .

Medical diagnosis is the process of determining which disease or condition explains person's signs and symptoms.

Pathophysiology of pneumonia: this disease is essentially when fluid or pus gets trapped in the alveoli of the lungs and gas exchange becomes impaired.

Pneumonia symptoms can vary from mild to severe, depending on the type of pneumonia you have, your age and health.

The most common symptoms of pneumonia are:

• Cough (with greenish or yellow mucus, or even bloody mucus)
• Fever, which may be mild or high
• Shaking chills
• Shortness of breath, which may only occur when you climb stairs

Additional symptoms include:

• Sharp or stabbing chest pain that gets worse when you breathe deeply or cough
• Headache
• Excessive sweating and clammy skin
• Loss of appetite, low energy, and fatigue
• Confusion, especially in older people

Symptoms also can vary, depending on whether your pneumonia is bacterial or viral.

• In bacterial pneumonia, your temperature may rise as high as 105 degrees F. This pneumonia can cause profuse sweating, and rapidly increased breathing and pulse rate. Lips and nailbeds may have a bluish color due to lack of oxygen in the blood. A patient's mental state may be confused or delirious.
• The initial symptoms of viral pneumonia are the same as influenza symptoms: fever, a dry cough, headache, muscle pain, and weakness. Within 12 to 36 hours, there is increasing breathlessness; the cough becomes worse and produces a small amount of mucus. There may be a high fever and there may be blueness of the lips.

Potential Complications:

Even with treatment, some people with pneumonia, especially those in high-risk groups, may experience complications, including:

• Bacteria in the bloodstream (bacteremia). Bacteria that enter the bloodstream from your lungs can spread the infection to other organs, potentially causing organ failure.
• Difficulty breathing. If your pneumonia is severe or you have chronic underlying lung diseases, you may have trouble breathing in enough oxygen. You may need to be hospitalized and use a breathing machine (ventilator) while your lung heals.
• Fluid accumulation around the lungs (pleural effusion). Pneumonia may cause fluid to build up in the thin space between layers of tissue that line the lungs and chest cavity (pleura). If the fluid becomes infected, you may need to have it drained through a chest tube or removed with surgery.
• Lung abscess. An abscess occurs if pus forms in a cavity in the lung. An abscess is usually treated with antibiotics. Sometimes, surgery or drainage with a long needle or tube placed into the abscess is needed to remove the pus.

Assessment findings include:
Inspection	increased respiratory rate increased pulse rate guarding and lag on expansion on affected side children with pneumonia may have nasal flaring and/or intercostal and sternal retractions
Palpation	chest expansion decreased on involved side tactile fremitus is increased
Percussion	dull over affected area
Auscultation	breath sounds louder than normal. bronchophony, egophony, whispered pectoriloquy present Crackles, fine to medium

DIGNOSTIC STUDIES OF PNEUMONIA

• Listening to your lungs, with a stethoscope, for a crackling or bubbling sound
• Chest X-ray
• Blood test to check white blood cell count
• Sputum tests (using a microscope to look at the gunk you cough up)
• A pulse oximetry test, which measures the oxygen in your blood

A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. NANDA-International formerly known as the North American Nursing Diagnosis Association is the primary organization for defining, distribution and integration of standardized nursing diagnoses worldwide

Nursing Diagnosis for Pneumonia:

1. Ineffective Airway Clearance
2. Impaired Gas Exchange
3. Risk for Deficient Fluid Volume
4. Imbalanced Nutrition
5. Acute Pain
6. Activity Intolerance
7. Risk for Infection

Nursing Diagnosis for Pneumonia:

1. Ineffective Airway Clearance
2. Impaired Gas Exchange
3. Risk for Deficient Fluid Volume
4. Imbalanced Nutrition
5. Acute Pain
6. Activity Intolerance
7. Risk for Infection

3 Nursing Diagnosis for Pneumonia and Nursing Interventions for Pneumonia

1. Nursing Diagnosis Deficient Knowledge : about the condition and the need for action

Related to:

• Less exposed to information
• Less to remember
• Misinterpretation

Possible evidenced by:

• Requests for information
• Statement of misconception
• Repeat mistakes

Expected outcomes are:

• Stated understanding of disease processes and treatment conditions
• Do changes in lifestyle

Nursing Interventions for Pneumonia :

• Review of normal lung function
• Discuss aspects of the inability of the disease, duration of healing and hope of recovery
• Provide written and verbal form
• Emphasize the importance of continuing effective cough
• Emphasize the need to continue antibiotic therapy for the recommended period.

2. Nursing Diagnosis for Pneumonia : Risk for Deficient Fluid Volume

Risk factors:

• Excessive loss of fluids (fever, sweating, hyperventilation, vomiting)

Expected outcomes are:

• Balance of fluid balance
• Moist mucous membranes, normal turgor, capillary filling fast.

Nursing Interventions:

• Assess changes in vital signs
• Assess skin turgor, mucous membrane moisture
• Note the report nausea / vomiting
• Monitor input and output, note the color, character of urine
• Calculate the fluid balance
• Fluid intake of at least 2500 / day
• Give the drug as an indication: antipyretic, antiemetic
• Provide additional IV fluids as necessary

3. Nursing Diagnosis : Pain (Acute / Chronic)

Related to:

• Inflammatory lung parenchyma
• Cellular reactions against circulating toxins
• Persistent cough

Possible evidenced by:

• Chest pain
• Headache, joint pain
• Protect an area hospital
• Distraction behaviors, restlessness

Expected outcomes are:

• Cause the pain is gone / controlled
• Show relaxed, rest / sleep and increased activity quickly.

Nursing Interventions:

• Determine the characteristics of pain
• Vital Signs Monitor
• Teach relaxation techniques
• Advise and assist the patient in the technique of chest compressions during episodes of coughing

Nursing Interventions	Rationale
Assess the rate and depth of respirations and chest movement.	Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung.
Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds: crackles, wheezes.	Decreased airflow occurs in areas with consolidated fluid. Bronchial breath sounds can also occur in these consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasms and obstruction.
Elevate head of bed, change position frequently.	Doing so would lower the diaphragm and promote chest expansion, aeration of lung segments, mobilization and expectoration of secretions.
Teach and assist patient with proper deep-breathing exercises. Demonstrate proper splinting of chest and effective coughing while in upright position. Encourage him to do so often.	Deep breathing exercises facilitates maximum expansion of the lungs and smaller airways. Coughing is a reflex and a natural self-cleaning mechanism that assists the cilia to maintain patent airways. Splinting reduces chest discomfort and an upright position favors deeper and more forceful cough effort.
Suction as indicated: frequent coughing, adventitious breath sounds, desaturation related to airway secretions.	Stimulates cough or mechanically clears airway in patient who is unable to do so because of ineffective cough or decreased level of consciousness.
Force fluids to at least 3000 mL/day (unless contraindicated, as in heart failure). Offer warm, rather than cold, fluids.	Fluids, especially warm liquids, aid in mobilization and expectoration of secretions.
Assist and monitor effects of nebulizer treatment and other respiratory physiotherapy: incentive spirometer, IPPB, percussion, postural drainage. Perform treatments between meals and limit fluids when appropriate.	Nebulizers and other respiratory therapy facilitates liquefaction and expectoration of secretions. Postural drainage may not be as effective in interstitial pneumonias or those causing alveolar exudate or destruction. Coordination of treatments and oral intake reduces likelihood of vomiting with coughing, expectorations.
Administer medications as indicated: mucolytics, expectorants, bronchodilators, analgesics.	Aids in reduction of bronchospasm and mobilization of secretions. Analgesics are given to improve cough effort by reducing discomfort, but should be used cautiously because they can decrease cough effort and depress respirations.
Provide supplemental fluids: IV.	Room humidification has been found to provide minimal benefit and is thought to increase the risk of transmitting infection.
Monitor serial chest x-rays, ABGs, pulse oximetry readings.	Followers progress and effects of the disease process, therapeutic regimen, and may facilitate necessary alterations in therapy.
Assist with bronchoscopy and/or thoracentesis, if indicated.	Occasionally needed to remove mucous plugs, drain purulent secretions, and/or prevent atelectasis.
Urge all bedridden and postoperative patients to perform deep breathing and coughing exercises frequently.	To promote full aeration and drainage of secretions.

Evaluating plan:

1. Obtain appropriate labs (antibiotic troughs, sputum cultures, ABGs, etc.)

   • Gives us a baseline; identifies pathogens, and enables us to evaluate if interventions are effective

2. Complete a full respiratory assessment to detect changes or further decompensation as early as possible, and notify MD as indicated

   • Enables quicker interventions and may change them (for example, wheezing noted on auscultation would potentially indicate steroids and a breathing treatment, while crackles could require suctioning, repositioning, and potential fluid restriction)

3. Promote normothermia (warm patient if hypothermic, cool patient and administer antipyretics if hyperthermic)

   • Normothermia optimizes oxygen consumption

4. Cluster care

   • Activity intolerance is common because of decreased gas exchange; cluster your care to conserve your patient’s energy for essential tasks like ambulation, coughing and deep breathing, and eating

5. Promote airway clearance

   • We want to encourage coughing to remove phlegm; do not suppress cough unless clinically indicated. If patient is able to clear their own airway, continue to encourage this. If not, suction frequently and consider an advanced airway to ensure a patent airway, which ultimately maximizes gas exchange. Getting phlegm out is important.

6. Optimize fluid balance

   • Patients with pneumonia may not be consuming adequate oral intake due to fatigue or not feeling well, but hydration is essential to healing. Patients may need IV fluids if PO intake is inadequate.

7. Assess and treat pain

   • If patients are not coughing because of pain, it will only allow fluid to continue to build. Treat pain appropriately and encourage them to cough to clear phlegm.

8. Encouraging coughing and deep breathing

   • Coughing and deep breathing encourages expectoration, which enables better gas exchange

9. Promote nutrition

   • Patients with pneumonia typically tire easily and have poor appetites, but need appropriate nutrition and hydration to heal

10. Administer supplemental oxygen as appropriate

    • Due to the impaired gas exchange, oxygen doesn’t make it into circulation as easily. Providing additional oxygen supports this as much as possible. Use caution in patients with underlying lung conditions.

11. Ensure patent airway

    • If a patient has unmanageable secretions or is unable to maintain consciousness and keep their airway clear, they must be supported (positioning, advanced airway, etc) to ensure adequate oxygen delivery

12. Promote rest

    • Energy conservation is essential; patients should focus on breathing, providing self care, coughing/deep breathing, and ambulation. Patients cannot adequately participate in these important activities if they are not maximizing their time to rest. Appropriate sleep promotes healing.

13. Administer antibiotics in a timely fashion, draw troughs appropriately

    • Patients may be on antibiotics, therefore it’s essential to ensure they are administered at the appropriate time and not delayed, as this will impair their efficacy. Also, trough levels will most likely to be ordered to assess if the patient is getting too much, too little, or just enough of the antibiotic. The timing of these labs related to administration times are essential for accuracy.

14. Prevent further infection

    • Patients may have invasive lines like a internal urinary catheter, central venous catheter, endotracheal tube, and so forth. It is essential to care for these devices properly to prevent further infection.

15. Educate patient and loved ones on the importance of energy conservation, effective airway clearance, nutrition, as well as coughing and deep breathing

    • Patients must be aware of how these aspect of recovery are pertinent so they will be more likely to participate and remain compliant.