Holistic Nursing Process Map Fatigue, SOB, Cough Risks for Developing Sepsis Pleural effusion Lung Abscess Bacteremia Respiratory failure Pathophysiology = RT Infection of the lungs that may be caused by bacteria, viruses, or fungi. The infection causes the lungs air sacs (alveoli) to become inflamed and fill up with fluid or pus. Diagnosing Disease Process Assessment Signs & Symptoms = AEB Respiratory Rate of 26 Fatigue Shortness of Breath Productive Cough (thick green/yellow sputum) Right middle and lower lung crackles Bilateral cervical lymphadenopathy Tachycardia Pulse 114 Decrease oxygen - SPO2 86% Fever - Temp 103.3 Pleuritic chest pain Shaking Chills R upper and middle lobe infiltrates indicative of pneumonia Scratchy throat Dyspnea Hypoxia Leukocytosis Diagnostics WBC 20,500 neutrophil 85 lymphocytes 5 band cells 20 SpO2 86 base excess -2.1 Medications Ceftriaxone Azithromycin Normal Saline Ketorolac Acetaminophen Benzonatate Guafenesin Education/Spiritual Needs: Refers to the “Art” of Nursing Education on how to use spirometer if ordered by MD Teach patient relaxation techniques/ deep breathing exercises Instruct patient to complete their antibiotic regimen Teach patient the different types of pneumonia Educate on the signs and symptoms Educate on the importance of being vaccinated Practice good hygiene Avoid being around people who are sick Refrain from smoking Help your immune system stay strong by eating a balanced diet, exercising regular, and getting enough sleep. Nursing Diagnosis Ineffective breathing pattern, related to pneumonia, as evidenced by respiratory rate of 26, labored breathing, and productive cough. Hyperthermia, related to pneumonia, as evidenced by temperature of 103.3 F related to dehydration, tachycardia, and tachypnea. Planning Nursing Intervention Patient will maintain a respiration rate of 20 breaths per min by suctioning secretions as needed and encouraging patient to mobilize secretions within 2 hours. Patient’s temperature will stabilize to 98 F by adjusting room temperature and administering acetaminophen within 2 hours.
