Question

? I need to make all final revisions on your evolving concept map. IN ADDITION, this week, evaluate each goal for completion, met or not met.

At least one goal should be designated as not met and a revised goal should be written with rationales for goal change.

Need help with the following concept map with the above instructions:

Medical Dx: Pneumonia

Pathophysiology:

Acute bacterial or viral infection that causes inflammation of the lung parenchyma. Lung tissue becomes edematous and air spaces fill with exudate, gas exchange cannot occur, and non-oxygenated blood is shunted into the the vascular system, causing hypoxemia. Bacteria pneumonia involved all or part of a lobe, where viral appear diffusely throughout the lungs.

Complications & Actions to Prevent:

Dyspnea-place patient in semi-fowler’s, monitor oxygen, ABGs, administer prescribed steroids, oxygen, antibiotics

Pleural effusion-Identify and treat the underlying cause, place in high fowler’s, monitor breath sounds

Pneumothorax-- place patient in semi-fowler’s, observe for hypoxia, assess breath sounds

Diagnostics:

Chest X-ray, Sputum for gram stain and culture, WBC, ABG values

Oximetry, Chemistry panel

Assessment:

Sign/symptoms: cough, increased sputum production (rust colored, discolored, purulent, bloody or mucoid), dyspnea, chills, headache, myalgia.

In order adults may be confused/disoriented and low-grade fever

Decreased skin turgor, flaring, expiratory grunt, use of accessory muscles of respiration, decreased breath sounds, low-pitched crackles(rales)

Risk Factors:

Smoking

Elderly

Air pollution

Status post-surgery

Nursing Diagnosis: (2)

1)       Ineffective Airway Clearance

2)       Risk for Infection

Goals: (4) ( 1 STG and 1 LTG for EACH NANDA)

1.       (STG) Patient demonstrates effective cough within 12 hrs.

2.       (LTG) Display patent airway with breath sounds clearing; absence of dyspnea, cyanosis prior to hospital discharge.

3.       (STG) Achieve timely resolution of current infection without complications within 12 hrs.

4.       (LTG) Patient is free of infection evidenced by normal WBC and sputum is clear prior to hospital discharge.

Nursing Interventions:

1.Ausculatate breath sounds q2-4h and report changes in patient’s ability to clear pulmonary secretions.

2. Teach patient to splint chest with pillow, folded blanket or crossed arms (reduces pain while coughing).

3. Teach and assist patient with deep breathing exercises.

4. Monitor vital closely. Administer medications.

5. Prior to d/c educate sign and symptoms of pneumonia, if any changes report to MD.

Answer 1

Medical Dx: Pneumonia

Pneumonia is the inflammation of air spaces in the lung in which infection may be caused due bacteria, virus, fungi or less frequent byother causes .The most common bacterial type is Streptococcus Pneumoniae. The inflammation of lung parenchyma results in formation of exudates within the lung that impairs the gaseous exchange.

Risk factors:

The risk factors include age over 65 and less than 2, underlying chronic disease condition, smoking, alcoholism, difficulty in swallowing, immunocompromised person, prolonged hospitalization with use of ventilator amd malnutrition.

Types of pneumonia:

A) Hospital acquired B) Community acquired

Other classification : A) Bacterial pneumonia B) Viral pneumonia c) Aspiration pneumonia

Signs and symptoms: Cough, chest pain while breathing, dyspnea, fever, chills, fatigue, cough produce phlegm.

Complications: Bacteremia, Difficult breathing, pleural effusion and lung abscess.

Diagnosis: Chest X-ray, pulse oximetry, blood and sputum culture, Bronchoscopy

Nursing care plan:

Assessment: Assess for the presence of signs and symptoms of the disease like cough with phlegm, cough is rust coloured may be purulent and often bloody, chest pain on breathing, dyspnea, fever with chills, Monitor for risk factors also.

Nursing diagnosis: Ineffective airway clearance, Risk for infection, Hyperthermia, Activity intolerance, Ineffective breathing pattern.

Goals:

• Patient will show effective breathing pattern within 12 hrs
• Achieve timely resolution of infection without any complication within 12 hrs
• Patient will have cleared airway with no signs of dyspnea, cyanosis or chest pain beofre discharge.
• Patient will depict normal body temperature within 12 hrs.
• Patient will learn to manage his activity according to his condition before discharge.

Nursing interventions:

• Auscultate the lung sounds and report the presence of exudates or secretions.
• Teach deep breathing and coughing exercise to help him in expulsion of secretion. Advice him to splint his chest while coughing.
• Provide semi fowlers position to comfort breathing.
• Monitor vital signs and report changes.
• Educate about the importance of hand hygiene and ways to prevent infrection.
• Teach to adjust and plan activity according to his tolerance level.
• Administer antiboitics and antipyretic medications as prescribed.
• Educate him about the clinical features of the disease and to contact physician if remission occurs.

Outcome/evaluation:

• Patient will show effective breathing pattern within 12 hrs ( Goal met)
• Achieve timely resolution of infection without any complication within 12 hrs(Goal partially met)
• Patient will have cleared airway with no signs of dyspnea, cyanosis or chest pain before discharge.(Goal met)
• Patient will depict normal body temperature within 12 hrs.(Goal not met)
• Patient will learn to manage his activity according to his condition before discharge.(Goal met)

From the list of above goals the patient will depict normal body temperature within 12 hrs was not met. SO it is revised to: Patient will depict normal body temperature within 24 hrs.