Student Name/Date _02/03/2020_
Disease Process _Pneumonia__
Pathology (at cellular level-Define tech terms)
Risk Factors/Causes (list classic &* if your pt has)
-Abdominal or thoracic surgery
-Age >65 yr*
-Air pollution
-Altered consciousness: alcoholism, head injury, seizures, anesthesia, drug overdose, stroke
-Bed rest and prolonged immobility
-Debilitating illness
-Inhalation or aspiration of noxious substances
-Intestinal and gastric feedings via nasogastric or nonintentional tubes
-IV drug use
-Malnutrition
-Resident of a long-term care facility
-Smoking
-Upper respiratory tract infection
Inflammation in the lungs results in filling of the alveolar
May lead air spaces with exudate, inflammatory cells, and fibrin.
The neutrophils present in the air spaces kill pathogens
to
by releasing enzymes and antimicrobial proteins. The
inflammatory injury causes the lining to secret mucus
secretions, reduced ventilation, and impair gas exchange.
Classic Treatments (* those pt receiving & specify
name of med your pt on)
Medical:
-PT daily*
-OT daily*
-SCDs while in bed*
Results
-Oxygen 2L NC prn to keep sats >92%*
Determin
e
-Control fever with aspirin or nonsteroidal antiinflammatory drugs*
_________________________________________
Nursing (include edu):
-Educated pt on importance of ambulation
-Out of bed for meals*
-IS q1hr while awake*
-Encourage deep breathing exercises, caution
patient to stop if feeling lightheaded or shortness
of breath
If treatment unsuccessful
Classic Complications (*those pt has- Define technical term)
-Atelectasis(collapsed, airless alveoli) of one or another
lobe in the lungs
-Pleurisy (inflammation of the pleura)
-Pleural effusion (fluid in the pleural space)
-Bacteremia (bacteria infection in the blood)
-Meningitis (inflammation of the protective membranes
covering the brain and spinal cord)
-Acute respiratory failure (damages the lungs ability and
the exchange of O2 and CO2)
-Sepsis/septic shock (occurs when bacteria within alveoli
enter the bloodstream)
--
Cite Sources (Lewis et al, 11th edition)_
Classic Imaging and Tests to confirm this Disease_
Test
Classic Result
Pt Result
-chest x-ray
-patchy or
infiltrates
-interstitial
infiltrates
Signs & Symptoms (list classic &* those pt has.
Define technical terms)
Manifests
As
-cough*
-fever* (low grade 99.8)
-chills
-Dyspnea*
-Tachypnea*
-Pleuritic chest pain
-Sputum* (yellow)
-confusion*
-stupor
-hypothermia
- Fine or coarse crackles*
Led to hospitalization
Patient Information: Initials _RB___ Rm # _301
Age_86_ Sex__M__ Adm Date ______ MD __Michael
-low O2 Sat (90%)
Chief
-92%
McCaffery__
Concern
Allergies _NKDA_ Code Status __FULL____
Prompts
Diet __Regular____Chief Concern _Shortness of breath
with activity and a productive cough_ Diagnosis
Comorbidity Abnormal Imaging and other Tests
_Pneumonia__
Surgery and Date:
Test
Result
Your Pt’s Etiology
V/S & Pain Level on Day of Care: _ Temp 99.8, Pulse 102,
-R hip X-ray:
-Intertrochanteric
-pt fell 2 weeks ago
Blood Pressure 166/87, Resp 24, O2 Saturation 92% on 2L
fracture of the
NC, Pain 3/10 _
femur, pelvic
Hendrich Score with interp ___5: High risk__
osteopenic
Braden Score with interp _18: Mild risk for pressure
ulcers
IV site: None (continuous or saline lock-circle one)
Activity Level: Weight bearing with walker, up adlib, out
of bed for all meals Tubes/Drains: None
Treatments (circle all ordered and list other) IS, O₂ SCDs,
Classic Lab Tests that confirm Disease Process
OT, PT, RT, Accu√, Dressing Chg, Other: _________
Test
Normal
Classic Trend Pt’s Result
New meds for new problems: enoxaparin, polyethylene
WBC
4.0-11.0
elevated
12.6 (HIGH)
glycol, hydrocodone/apap, lisinopril,
Sputum
Negative
Positive
Not done
Currently pt is ( circle one: improving/stable/ worsening)
culture
& state supporting rationale :
RB is not participating in PT at this time, refusing to
transfer OOB for meals.
Comorbidity Abnormal Lab Results
Past Med/ Surgical History (* those R/T admit)
Test
Normal
Pt’s Result Etiology
-Hypertension
-Gastroesophageal reflux disease
HgB
11.5-15.4
9.9 (Low)
Anemia-blood
-Chronic joint and back pain
Hct
34.0-45.0
29.4(Low)
loss
-Benign prostatic hyperplasia
Calcium
8.8-10.5
8.0(Low)
Anemia-blood
-Right forearm fracture (two years ago)
RBC
3.80-5.10
2.83(Low)
loss
-Tonsillectomy (age 15)
Albumin
3.5-5
3.0 (Low)
Hypocalcemia
Recent
-Cataract removal (1998)
surgery
-Fracture Right Ulna (2009)
Poor appetite
-Fracture Right Hip two weeks ago with ORIF*
-pulse oximetry
Student Name/Date:
NPR Steps 2-5 (DIAGNOSIS, PLANNING, INTERVENTON, EVALUATION)
Step 2: NANDA
Nursing Diagnosis
Step 3: Planning SMART
Goal
#1 Nursing Diagnosis- Infective Airway Clearance
R/T Retained secretions
AEB: Course lung sounds, yellow septum, and shortness of
breath
Plan: Pt. Smart Goal- To address ineffective airway
clearances, RB will have oxygen saturation level of at least
95% by the end of the shift.
RB will demonstrate proper incentive spirometer technique
before and after each meal by the end of the shift today.
Nursing Interventions
1. Auscultate Breath sounds every 1 to 4 hours.
Clinical Research: Breath sounds are normally clear to
scattered fine crackles at bases, however coarse crackles
indicate fluid in the airway, and wheezing indicated an
obstructive airway.
(Faucl et al, 2008 in Ackley, 11th pg 131)
2. Help the client to deep breath and perform controlled
coughing. Have pt. inhale deeply, hold breath for several
seconds, and cough twice with mouth open while tightening
upper abdominal muscles.
Clinical Research: Controlled coughing uses the diaphragm
muscles which makes the cough more forceful and effective
(Gosselink et al, 2008 in Ackley, 11th pg 132)
3. Teach importance of the incentive spirometer and
emphasize its impact on keeping clear airways and improving
clients pneumonia.
Clinical Research: Inceptive spirometer as well as controlled
coughing and deep breathing have a positive impact on
airway clearance.
(Gosselink et al, 2008 in Ackley, 11th pg 132)
Evaluation: Goal not met. RB’s lungs demonstrated crackles
upon auscultation in all lung fields. RB was unable to perform
deep breathing exercise. RB compliments of being “short of
breath”. RECOMMENED: Attempt ambulation when RB is
alert, such as shortly after breakfast. Limit physical activity
before deep breathing exercises to avoid shortness of breath.
Step 4: Interventions & Research
Rationale
(cite research from Ackley)
Step 5: Evaluation * Met, Partially Met, or Not
Met,*In patient terms, summarize the patient’s
response to interventions
#2 Nursing Diagnosis- Impaired physical mobility
R/T Activity intolerance, anxiety, decreases in muscle
strength/control, muscle disuse, chronic pain, malnutrition
AEB: Discomfort slow movement, uncoordinated movement,
alteration in gait.
Plan: Pt. Smart Goal– In order to address impaired physical
immobility, RB will ambulate 20 ft. down the hallway and back
after breakfast and lunch during my shift.
#3 Nursing Diagnosis- Risk for fall
R/T : Altered cognitive function or confusion, polypharmacy, age
greater than 65, sleeplessness, impaired mobility, decreased
physical strength, decreased lower extremity.
AEB:
Plan: Pt. Smart Goal- In order to address risk for falls RB will
demonstrate pressing the call bell before getting out of bed by
the need of my shift.
Nursing Interventions
Nursing Interventions
1. Before activity, observe for and if possible, treat pain with
massage, heart pack to affected area, or medication, Ensure that
the client is not sedated.
Clinical Research: Pain limits mobility, and if exacerbated by
specific movement should be temporality avoided.
(America College of Sports and Medicine, 2018, 12th pg 621)
1. Screen all clients for mobility skills
Clinical Research: Helpful to determine the clients functional
abilities and then plan for ways to improve problem areas or
determine methods to ensure safety.
(Podsiadio & Richardson, 1991 in Ackley, 12th pg 372)
2. Asses for fear of falling
Clinical Research: Self-reported fear of falling has been shown to
be a significantly more sensitive predictor for fall risk than the
STRATIFY fall risk assessment tool.
(Strupelt, Buss, & Wolf-Ostermann, 2016, 12th pg 621 )
2. When rising from a lying position, have the client change
position slowly, dangle legs, and stand next to the bed before
walking to prevent orthostatic hypotension.
Clinical Research: Encourage client engagement in a monitored
exercise program that will strengthen and lower extremities to
reduce fall risk.
(Grablner, 2013; Hirase et al, 2014 in Ackley 12th pg 372)
3. Increase activity tolerance with graded increase in self-care,
such as bathing, walking to the bathroom, and ROM.
Clinical Research: A study of FFC in older adults hospitalized after
trauma found greater improvement in function, less fear of
falling, and better physical resilience than controls at discharge
and 30 days after discharge.
(Resnick, Gallk, &Vigne, 2016 12th pg 621)
Evaluation: Goal partially met. RB was only able to ambulate 50 ft
with assistance once by the end of my shift. RB complained of
pain of 6.10 and fatigue when attempted to ambulate the second
time during my shift. RECOMMEND: teaching RB to call nurse for
pain wherever 4.10 and to notify nurse of tolerable level of
exercise.
3.Teach the client how to safety ambulate at home
Clinical Research: per Subject Matter Expert
(Greenberg, 2020 in Ackley 12th, pg 376)
Evaluation: Goal was met. RB was taught and was able to
performed ambulation safety. RB changed positions slowly to
prevent orthostatic pressure. RECOMMED: continue to
encourage RB to engage in exercise programs that will
strengthen his lower extremities to reduce his risk for falling.