University:
West Coast University
Course:
NURS 110 | Introduction to Professional Nursing
Academic year:

2021
Views:

448

Pages:

1
Author:

esfredint7qo

Hypostatic Pneumonia Pathophysiology (In your own words-cite reference) Def:Inflammation of the lung Assessment Data- min. of 3 Subjective: Nursing Interventions for 1.productive cough 2. shortness of breath parenchyma caused by various Nursing Diagnosis/Priority Problem #1 3. Vomiting (3-part statement) microorganisms, including bacteria Objective: mycobacteria, fungi, and viruses. 1. fever: 101 °F Caus Org: Lung decrease 2. O2 saturation level: 89% Clin. Mani: Productive cough, SOB, 3. Tachycardia Ineffective thermoregulation related to infection process as evidence by fever of 101F. Goal #1- min. of 2 1. Assess patient’s vital signs at Least every 4 hours. Rationale: To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment particularly antibiotics and fever- vomiting, fever, tachycardia. reducing drug such as Tylenol Pathophys: decrease ventilation of Planning- Short Term Goal #1 lungs 1. Patient’s temperature will reduce administered. 2. Remove excessive clothing, blankets and linens. Adjust room Ref: to 98F by increasing fluid intake and Thomas Jr, C. F., & Limper, A. H. (2004). Pneumocystis removing excess clothing within 24 hours Rationale: To regulate temperature Diagnostic Procedures: of the environment and make it pneumonia. New England Journal of Medicine, 350(24), 2487- temperature. 2498. more comfortable for the patient. Ref: Planning- Short Term Goal #2 Nursing Diagnosis/Priority Problem #2 1. Patient will demonstrate effective breathing techniques (3-part statement) within 48 hours by using an incentive spirometer. Ineffective airway breathing related to Diagnostic Procedures: inflammation and presence of secretions as evidenced by O2 saturation level of 89% Evaluation- Was the goal met, what evidence would support the goal being Nursing Interventions for Goal #2- min. of 2 1. 2. met. If goal was unmet, what will you do next? Administered oxygen therapy and use as prescribe. STG #1- Goal was not met. Patient temperature was 100F after 24 hours. Rationale: Using a oxygen therapy continuously every 2 hours Teaching: Having patient to remove excess clothing and increase fluid intake to Breathing techniques every 4 hours by using an incentive 2500mL per day. spirometer. Rationale: Using incentive spirometer helps the expansion of the lungs. Ref: Diagnostic Procedures: STG #2- Goal was met. Patient O2 saturation level was at 98% after 48 hours.