Question

Location: Medical Unit 1600

Report from day shift nurse:

Situation: Mrs. Hernandez is a 72-year-old Hispanic female who was admitted to the medical unit yesterday afternoon with a diagnosis of pneumonia in her right lobe. Chest X-ray shows infiltrates in right lower lobe, indicative of pneumonia. She was started on antibiotics after a sputum specimen for Gram stain culture was obtained. We are monitoring her respiratory status closely.

Background: Mrs. Hernandez was experiencing symptoms of dry cough, fever, and malaise, and was diagnosed with influenza 10 days prior to admission. Her symptoms got progressively worse, and yesterday she had a temperature of 38.4 °C (101.2 °F), shaking, chills, and a productive cough of rust-colored sputum. Her primary care provider saw her yesterday and decided to admit her for treatment of pneumonia.

Assessment: Mrs. Hernandez is alert and oriented ×3, but appears tired. She reports sharp chest pain with coughing and shortness of breath with activity. She rated the pain as a 6 on a scale of 0–10 and was given acetaminophen 650 mg at 1400. Vitals signs were taken at 1200. Her temperature has been elevated since this morning and was 38.1 °C (100.6 °F). Pulse is 104/min, respirations 24/min, and blood pressure 112/72 mm Hg. Her saturation was 95% on nasal cannula with oxygen at 3 L/min. Her respirations were labored when she came back from the bathroom, but improved when she settled back in bed.

Recommendation: You should make sure to maintain saturation levels above 94%. Mrs. Hernandez needs encouragement to cough and deep breathe, and to use incentive spirometry. She only uses her incentive spirometer after much encouragement. You should also start patient education on disease process and management.

Fundamentals of Nursing Care

1. Taylor, C., Lynn, P., Bartlett, J. (2019). Fundamentals of Nursing: The Art and Science of Person-Centered Care, 9th Edition.
2. Assessing the Thorax and Lungs, Chapter 26, pp. 714-716
3. Promoting Comfort; Promoting Proper Breathing; Promoting and Controlling Coughing, Chapter 39, pp. 1502-1505
4. Using a Pulse Oximeter, Chapter 39, pp. 1524-1525
5. Administering Oxygen by Nasal Cannula, Chapter 39, pp. 1449-1452
6. Acid-Base Imbalances, Chapter 40, p. 1567
7. Acid-Base Disturbances, Chapter 40, p. 1574, Table 40-6

Diseases and Conditions

1. Expert Clinical Content from Lippincott Advisor
2. Pneumonia Pneumonia

Nursing care plans for medical diagnoses

1. Expert Clinical Content from Lippincott Advisor
2. Pneumonia Pneumonia

Procedures

1. Expert Clinical Content from Lippincott Procedures
2. Oxygen administration Oxygen administration
3. Incentive spirometry Incentive spirometry
4. Safe medication administration practices, general Safe medication administration practices, general
5. Ambulation, progressive Ambulation, progressive

Assessment- 2 subjective data, 2 objective data

One nursing diagnosis

Goals- 2 long term goals, 2 short term goals

interventions- 4 interventions with rationales

Evaluation- 4 evaluations of goals, 4 evaluations of intervention

Answer 1

Answer :-

Long term goals :-

1.Need daily assesment of lungs and thorax so that any complication could he avoided.

2. Regular Physician check up is must.

Short term goals :-

1. Proper first aid for Pneumonia.

2. Treatment for acute chest pain

* Interventions:

1. Antibiotics for Pneumonia

2. Regular Oxygen Saturation Check up if fell belows 94 percent.

3. Exercises for Respiratory Pain.

4. Proper check up for Lungs and thorax

* Evaluation of Goals :-

1. Regular check up for evaluation of all tests.

2. Overall health condition of Patient.

3. Need to check saturation level of Patient

4. Respiratory Condition need to be evaluated.

* Evaluation of Interventions :-

1. Need to have feedback of the results.

2. All the medical records of intervention must be assessed.

3. Upto date maintainance of results record.

4. Self Assesmemt of medication after assesment