Nursing Care of a Patient Diagnosed with Pneumonia Essay

persevering Description persevering is a Caucasic 83 year old female that came into the emergency department from Wynwood sanction living facility with an accession of fatigue, worsening confusion and a 1 day history of a fever. persevering weighs approximately 90 pounds upon entrance money with a height of 64 inches. Patient has known COPD and is a spring heavy smoker that also has a history of pneumonia, hypertension, atrial fibrillation, and dementia. Upon intromission to the emergency department unhurried has had increased nasal drainage and cough out. Patient came into the hospital about a year and a half past with a diagnosing of right lower lobe pneumonia. Patient was arous adequate to(p), alert and pleasant, hardly not a good historian and appears to be quite emaciated. Patient at first had a non productive cough and was put on anti-biotics and began to have a productive cough 2 days spatial relation admission. Patient had dyspnea, increase respiration ordain, bother talking, coarse lungs, and had decreased SpO2 with bodily function.Patient lived in Wynwood assisted living facility where she lived almost indep demiseently. Patient was able to get around her apartment with a front wheel carriage and provided her own administer of activities of daily living. With this admission, hospital staff did not barrack patient going back to assisted living as she would not be able to take care of her self until her mobility is back to her formula limits and the dyspnea is decreased.Nursing DiagnosisIneffective airline clearance r/t bronchospasm, excessive mucous production, tenacious secretions, fatigue AMB dyspnea, increase RR (28), difficulty talking, inability to raise secretions, ineffective cough, adventitious br downh sounds.GoalsA. Pt testament demonstrate effective expectorate and clear breath sounds by goal of break 5/15/10 (3 days) and until discharge. B. Pt volition go along to have cyanotic free skin by terminal of shift on 5/14/10 (2 days) and until discharge. C. Pt bequeath maintain a patent airway at all times by end of shift 5/15/10 (3 days) and until discharge. D. Pt testament subsume methods to enhance secretion removal (drinking warm fluids) by end of shift 5/15/10 (3 days) and until discharge. E. Pt will relate the conditional relation of changes in stolidity to include color, character, amount and odor by end of shift 5/15/10 (3 days) until discharge.Interventions Rationale1. RN will auscultate breath sounds Q4 hrs and PRN until discharge. 2. RN and CNA will monitor respiratory patterns, including rate, depth, and effort Q4 hr and PRN until discharge. 3. RN will monitor tune gas values as available and pulse oxygen fertilization levels Q8 hr and PRN until discharge. 4. RN and CNA will function the client to optimise respiration (HOB elevated 45 degrees and repositioned every 2 hrs) and PRN until discharge. 5. RN and CNA will admirer the pt deep breathe and perform controlled coughin g Q2hrs until discharge. 6. RN will help the pt use the forced expiratory technique, the huff cough. The pt does a series of coughs while aphorism the word huff q4hr and PRN until discharge. 7. RN or CNA will assist with clearing secretions from pharynx by offering tissues and gentle suction of the spontaneous pharynx if necessary Q4 hr and PRN until discharge. 8. RN will remark sputum, noting color, odor and volume PRN until discharge.9. RN and CNA will encourage activity and ambulation as tolerated TID and PRN until discharge.10. RN and CNA will encourage fluid aspiration of up to 2500 mL/day within cardiac or renal reserve Q2 hrs and PRN until discharge. 11. RN will administer oxygen as ordered until discharge12. RN or RT will administer medications such as bronchodilators or inhaled steroids as ordered until discharged. 13. RN and CNA will monitor the patients behavior and mental status for the onset of informalitylessness, agitation, confusion and utmost(prenominal) letha rgy twice a shift and PRN until discharge date. 14. RN and CNA will observe for cyanosis of the skin twice a shift and PRN until discharge. 15. RN or CNA will position patient over bedside table for shrewd dyspnea PRN until discharge. 16. RN & CNA will help pt eat frequent small meals anduse dietary supplements PRN until discharge. 17. RN will teach pt energy conservation techniques and the importance of alternating rest periods with activity by end of shift tomorrow and PRN until discharge. 1. The presence of coarse crackles during late inspiration indicates fluid in the airway asthmatic indicates a narrowed airway (Simpson, 2006, p. 487).2. A normal respiratory rate for an adult without dyspnea is 12-16. With secretions in the airway, the respiratory rate will increase (Simpson, 2006, p. 486).3. An oxygen saturation of less than 90% or a incomplete pressure of oxygen of less than 80 indicates signifi atomic number 50t oxygenation problems (Sanford & Jacobs, 2008, p. 125).4. An upright position allows for maximal lung expansion lying flat cause abdominal variety meat to shift toward the chest, which crowds the lungs and makes it more difficult to breathe (Sanford & Jacobs, 2008, p. 125).5. This technique tail assembly help increase sputum clearance and decrease cough spasms. Controlled coughing was the diaphragmatic muscles, make the cough more forceful and effective (Sanford & Jacobs, 2008, p. 125).6. This technique prevents the glottis from closing during the cough and is effective in clearing secretions in the central airways (Sanford & Jacobs, 2008, p. 126).7. In the weaken client, gentle suctioning of the posterior pharynx may stimulate coughing and removing secretions (Sanford & Jacobs, 2008, p. 126).8. natural sputum is clear or gray and minimal abnormal sputum is green, yellow, or bloody malodorous and often copious (Sanford & Jacobs, 2008, p. 126).9. Body terminatements helps call back secretions and back end be a powerful means to mainta in lung health (Sanford & Jacobs, 2008, p. 126).10. Fluids help minimize mucosal drying and maximize ciliary action to move secretions. Some pts johnnot tolerate increased fluids because of underlying disease (Sanford & Jacobs, 2008, p. 126).11. Oxygen has been shown to illuminate hypoxia, which can be caused by retained respiratory secretions (Sanford & Jacobs, 2008, p. 126).12. Bronchodilators decrease airway resistance secondary to broncho-constriction (Sanford & Jacobs, 2008, p. 126).13. Changes in behavior and mental status can be early signs of impaired gas exchange. In the late stages the patient becomes lethargic and somnolent (Sanford & Jacobs, 2008, p. 388).14. Central cyanosis of the tongue and oral mucosa is asserting(a) of serious hypoxia and is a medical emergency. Peripheral cyanosis in the extremities may or may not be serious(Sanford & Jacobs, 2008, p. 388).15. Leaning forward can help decrease dyspnea, possibly because gastric pressure allows better condensate of the diaphragm. This is called the tripod position and is used during times of distress (Sanford & Jacobs, 2008, p. 388).16. Improved nutrition can help increase muscle aerobic capacity and exercise tolerance. nutritional problems in clients with COPD can be visual early identification of clients at risk is essential to maintaining BMI (Sanford & Jacobs, 2008, p. 389).17. Fatigue is a common symptom of COPD and ineluctably to be assessed and managed (Sanford & Jacobs, 2008, p. 390).Article SummaryIn the Article, Respiratory Assessment, by Heidi Simpson, intends for the audition to be nurses already working in the field. This expression gives an order of a respiratory judgment that works for any nurse, whether they are a brisk graduating nurse or a nurse who has been working for years. This journal article gives all the required elements in order to do a full-of-the-moon respiratory judging which includes the initial judicial decision, history taking, inspection, palpitatio n, percussion, auscultation, and further investigations (Simpson, 2006, p. 484). This article is a general information article that focuses towards all and any patient universe as all of our patients need to have a respiratory assessment done. This article gives a good breakdown of a respiratory assessment in which I currently use in practice. The article can be a good reminder of how an accurate respiratory assessment should be done and how to get good results in the technique a nurse may use.ReferencesSanford, J.T. & Jacobs, M. (2008). Impaired gas exchange. In B.J. Ackley & G.B. Ladwig (Eds.) Nursing diagnosis handbook An evidence-based guide to planning care (8th ed., pp. 388-390). St Louis, MO Elsevier. Sanford, J.T. & Jacobs, M. (2008). Ineffective airway clearance. In B.J. Ackley & G.B. Ladwig (Eds.) Nursing diagnosis handbook An evidence-based guide to planning care (8th ed., pp. 124-129). St Louis, MO Elsevier. Simpson, H. (2006). Respiratory assessment. British Journal ofN ursing (BJN), 15(9), 484-488. Retrieved from CINAHL with full textbook database.