1. using the nursing process, develop two plans of care – 1 related to one priority
physiological nursing diagnosis and 1 related to one priority psychosocial nursing
Case Study: Hospital Acquired Pneumonia
Chamberlain College of Nursing
NR324: Adult Health
Mr. JJ, is an 89 years old Caucasian male, 5 10 (178 cm) tall, and his weight is 165 Ibs and he is full code. He was brought into the emergency department on 03-22-202 for acute confusion and cough. His wifes chief complaint to the emergency medical services is that she noticed her husband has become more lethargic and displayed odd behaviors. She said he has been putting a shirt on backwards and reading the newspaper upside down and not responding as usual. She also said that he has not had much to eat or drink in the past 24 hours. He has a past medical history of hypertension and mild Alzheimers disease, alcoholism, smoker. At admission he displayed signs of pneumonia, but with no previous hospitalization or surgery.
Laboratory/Diagnostic Testing: a complete history and physical examination to create a baseline for any risk that might be present. patient BP assessment indicated hypotension, his heart rate indicated tachycardia, and abnormal respiration of 26, labored. Temperature of 100.2 Fahreient, which could indicate low fever, and a low oxygen saturation of 90% on room air. Mr. J.J was unable to answer questions due to confusion, but there was no indication of pain. His skin was clean, warm, and dry without lesions, his skin is without tents over the clavicle after a pinch test. Braden skin assessment score was 18 indicating mild risk. His eyes conjunctiva is pink, its without discharge, and his eye is sclera anicteric. His lips were dry and cracked which could be as result of dehydration and I was unable to inspect oral cavity. The cardiovascular region is a regular rhythm, his capillary refill is less than 3 seconds, no edema, no productive cough and lungs were clear to auscultate except for crackles in the lower right lobe. J.J was uncooperative; I was unable to assess his gastrointestinal. Lower and upper extremities were within functional range. A chest x-ray was completed and it showed pulmonary infiltrates in the right middle lobe and a pending order for blood culture was ordered to find out if the patient has a bacterial infection that has spread to the bloodstream. 12- lead EKG was ordered to provide more information on diagnosis of cardiac arrhythmia, complete blood count text was ordered, as well as urine text and comprehensive metabolic panel or CMP to assess all electrolyte values.
Mr. Johnson is taking prescription medications to treat the preexisting condition prior to his admission to the hospital. Medication include Donepezil 10 mg PO q HS, Levaquin 500mg IV every 12 hours, Enoxaparin 40 mg subcutaneous daily, normal saline (0.9%) at 75 ml/hr. Ipratropium bromide/ albuterol sulfate per uint dose per nebulizer treatment every 4 hours. If the chest x -ray and the blood test indicate pneumonia, a more specific antibiotic therapy maybe for pneumonia with O2 therapy will be initiated to treat hypoxemia, antipyretics such as aspirin, acetaminophen for fever, and cough suppressants such as mucolytics, bronchodilators & corticosteroids as well as diuretic medication which can be used for impaired gas exchange. Dietary prescriptions included may include IV administration of fluids and electrolytes, offer foods that looks palatable, high in calories, proteins, and nutrients.
Key/relevant roles: Members of the healthcare team would include the healthcare physician who will diagnosis the patient, create a plan of care, create an appropriate list of medications, as well as communicate with the nurse to better help and care for the patient. The next team member is the nurse, who will create a baseline assessment, follow doctors orders, monitor the patient and document all patient findings, form a bond with the patient, and communicate with the patient and family. Registered dietician is also a part of the team who will create a baseline of their overall nutritional status, adjust diet as needed, and form a homecare nutritional plan. Lastly, the family, who will help to support as well as advocate for the patient.
Risk of infection related to elevated temperature and unproductive cough
Nursing diagnose 1
Nursing diagnose 1
Risk for deficient fluid volume related to decrease intake