Question

Care Plan: 84 y/o F adm c bacterial pneumonia. She is a retired bank manager and has been a widow for 15 yrs. Lives at home with a 45 y/o caregiver. Prior to admission, would take daily walks to the park with assistance of her caregiver and a walker. She does most of her ADLs-- caregiver prepares all meals. Pt has had a URI (Upper Respiratory Infection) for the past week. Over the last 2 days, she has experienced increased malaise and weakness. Three days ago, pt developed a cough that has increased in intensity. She has become increasingly SOB. Last night she became confused and almost fell going to the bathroom. She has been coughing up a large amount of thick, green sputum. She has been a smoker for 64 yrs. Currently smokes 1/2 ppd (pack-per-day). Suffered a stroke 4 yrs ago with mild left sided weakness. Influenza vaccine received 3 months ago. She's been experiencing depression for the last 3 months. She has also been constipated and incontinent of urine for the past 6 months. Strong family history of hypertension. Ht 5'10" Wt 124 lbs Current meds: Atenolol 100 mg po q day ; HCTZ 25 mg po daily; ASA 325 mg po q daily; nortriptyline 75 mg po q day; combuvent MDI 2 puffs QID prn; Albuterol MDI 2 puffs q 4 h PRN; docusate sodium 100 mg po hs Admission VS: B/P 140/85; pulse 95 reg, RR 28 & labored; Temp 98.3 (oral); O2 sat 88% on RA (room air) Abnormal labs: WBC 15,200 Pt admitted for o2 therapy; bronchodilators and prednisone. She becomes increasingly oriented, agitated, dyspneic, and cyanotic. Current VS: HR (pulse) 125; RR 35 and increasingly labored. O2 sats 90% on 2L via NC (nasal cannula)

complete nursing diagnosis of bacterial pneumonia?

Answer 1

I hope you will rate my answer positively --

Nursing diagnosis for pnemonia depends upon the assessment of coughing , patient air transfer technique, strength of secretions, suctioning method , viscosity level of the decrement.

Pnemonia is basically lung infections that causes inflammation of the parenchyma of lungs .bacterial pnemonia is commonest one . pnemonia can be community acquired, health care acquired, hospital acquired .common sign and symptoms associated with pnemonia is fever, coughing, cold, flue, shaking, vomiting, nausea, deep breathing, chest pain, pain while coughing, weak immunity, etc.

Nursing diagnosis for bacterial pnemonia are -

She assists the patients in following states for proper treatment-

1. Monitor the patients condition about oxygenation, and impaired gaseous exchange.

2. Assess the patient impaired airway clearance about edema, and inflammation.

3. She can also check activity tolerance, hyperthermia, infections risks.

4. Follow the acute pain nursing diagnosis to treat lung inflammation and a constant coughs.

5. Risk for deficient fluid volume.

6. Risk for imbalanced nutrition.

7.ineffective breathing Patterns.

Nursing interventions are --

1. Obtain appropriate sputum culture, antibiotic trough, arterial blood gas analysis.

2. Full respiratory assessment should be done, to see changes as early as possible.

3. Promote normothermia to the patient .

4. Promote airway clearance.

5. Optimum fluid baly is given.

6. Asses and treat pain.

7. Encourage for coughing and breathing.

8. Provide nutrition .

9. Give supplemental oxygen .

10. Ensure patent airway and provide rest .

11. Administer antibiotics timely and prevent further infections.

12. Educate patient.

Thankyou.