Question

b?Harri smith,70 years of age, is a male patientwho is admittedto the medical-surgical unit with acute community-acquired pneumonia.He was diagnosed with paraseptal emphysema 3 years ago.The patient smoked cigarettes onepack per day for 55 years and quite 3 years ago.The patient has a history of hypertension, and diabetes controlled with oral diabetic? agents.The patient presents with confusion asto time and place.The family stated that this is a new change for the patient.The admission vital signs are as follows: blood pressure 90/50mmHg, heart rate 101bpm, respiratory rate 28breaths/min,and temperature 105 F.The pulse oximeter on room air is 85%.The CBC is as follows: WBC 12,500, platelets 350,000, HCT 30%, and Hgb 10 g/dl. ABGs on room air are pH 7.30,PaO2 55, PaCO2 50,HCO3 25.Chest x-ray results reveal right lower lobe consolidation, presence of apical bullae, flattened diaphram, and a small pleyral effusion in the right lower lobe.Lung auscultationreveals severely diminished breath sounds in the right lower and absence of breath sounds at the base. The breath sounds in the rest of the lungs are slightly decreased. The patient complains of fatigue and shortness of breath and cannot finish a short sentence before the respiratory rateincreases above the baseline and his nail beds and lips turn a bluish tinge and the pulse oximetry decreases to 82%. The patient is diaphoretic and is using accessory muscles. The coughs weakly, but he does not raise any sputum.

a. what nursing assesment findings support the diagnosis of pneumonia?

b. What diagnostic findings support the diagnosis of pneumonia?

c. what nursing diagnosis should the nurse formulate for the patient?

d. What goals should the nurse develop for the patient?

e. What overall interventions should the nurse provide?

Answer 1