Patient assignment: Briefly state your patient assignment: Pneumonia, 48, alcohol withdrawal, denied smoking and drug abuse
Clearly indicate which ONE of your patients from above you will be discussing:
Pneumonia is not contagious but it is the germs called bacteria or viruses causes pneumonia. Pneumonia starts when you breathe the germs into yours lungs. You may get the disease after having a cold or the flu, that is hard for you to fight the infection so it easier to get pneumonia. For person with bacterial pneumonia will stop being contagious within 2 days of taking antibiotics. Complications such as bacteria in the bloodstream (bacteremia), difficulty breathing, fluid accumulation around the lungs (pleural effusion), and lung abscess are among the symptoms. Spread –depending on infections agents, usually, the organism spread from the person by contact with an infected persons mouth or when droplets become airborne from coughing and sneezing. Pneumonia affects the lung when germs that cause pneumonia reach your lungs air sacs (alveoli) become inflamed and fill up with fluid. This causes the symptoms of pneumonia such as cough, fever, chills; trouble breathing when you have pneumonia, oxygen may have trouble reaching your blood.
Pneumonia is an infection of the lungs. The lungs are made up of small sacs called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing painful and limits oxygen intake. Many different germs can cause pneumonia, including bacteria, viruses, and fungi.
Crackles are discontinuous, explosive, “popping” sounds that originate within the airways. They are heard when an obstructed airway suddenly opens and the pressures on either side of the obstruction suddenly equilibrates resulting in transient, distinct vibrations in the airway wall (Freifeld et al. 2011). The dynamic airway obstruction can be caused by either accumulation of secretions within the airway lumen or by airway collapse caused by pressure from inflammation or edema in surrounding pulmonary tissue. Crackles can be heard during inspiration when intrathoracic negative pressure results in opening of the airways or on expiration when thoracic positive pressure forces collapsed or blocked airways open. Crackles are heard more commonly during inspiration than expiration (Dodek, et al.2004). They are significant as they imply either accumulation of fluid secretions or exudate within airways or inflammation and edema in the pulmonary tissue.
Breathing: W,G admitted to medicine with
1) Ineffective airway clearance related to excessive secretion secondary to infection.
ncpnanda.com/priority-nursing-diagnosis-and-interventions-for-pneumoniacharacterized by mixed sputum of patients complaining of cough, productive cough such as sputum or dry cough secretions hard to get out, sputum scanty,colour clear, thin consistency,
Additional breath sounds (eg crackles during inspiration when intrathoracic negative pressure results in opening of the airways or expiration when thoracic positive pressure forces collapsed or blocked airways abnormal, heard most commonly on during inspiration than expiration, adventitious sounds rales and crackles).
Rationale: Retained secretions can obstruct airways, leading to an impaired gas exchange (Mandell et al.2003). Though client denied that he is smoking, I want to include in the interventions of ineffective clearance todiscourage smoking that increase accumulation of mucusproduction and improve ciliary function as smoking is a contributing factor.
2)Acute pain related to inflammation of the lung parenchyma
characterized by a patient complaining of chest pain, looks grimacing, checks vital signs: increased pulse (tachycardia) Rationale: chest pain are usually present in some degree in pneumonia, can also arise complications such as pericarditis and endocarditis, changes in heart rate or BP indicates that the patient is experiencing pain, analgesics reduce the pain. Retained secretions can obstruct airways , leading to an impaired gas exchange that cause pain during inspiratory and expiratory breathing.allnurses.com › Nursing Student › Nursing Student Assistance
3) Ineffective breathing pattern related to excessive secretion secondary to infection.
Characterized by the patient complained of difficulty breathing, looked tight, checks vital signs: respiration increases, afebrile 38.5C (Freifeld et al. 2011).
Physical examination: the use of accessory muscles, bronchial breath sounds.
Rationale: Inadequate primary defenses (decreased ciliary action, stasis of respiratory secretions).Inadequate secondary defenses (presence of existing infection, immunosuppression), chronic disease, malnutrition.
4) 6) Hyperthermia related to inflammation of the lung parenchyma.
Characterized by the body heat, seemed to shiver, and checks vital signs: temperature increases 38.5C, increase PR.
Rationale: Bacterial pneumonia in adults carries an elevated risk for adverse cardiac events (such as heart failure, arrhythmias, and heart attacks) that contribute substantially to mortality (Mandell et al.2003). A study now demonstrates that Streptococcus pneumoniae, the bacterium responsible for most cases of bacterial pneumonia, can invade the heart and cause the death of heart muscle.
List all scheduled medications for this patient and relate to patients current condition or to a past medical history condition.
I obtained informed consent for all assessments and interventions prior to doing them. I explained I was going to do a health assessment and that it would take 15 minutes. I also informed the pt afterwards of the findings.
Caritas Processes: Which Caritas process did you integrate into your care?
Provide an example of how you demonstrated ‘safe’ patient care? What unsafe situations did you observe and how did you restore a safe environment for the patient?
Notified the co-assign when SaO2 was 95%, noticed the room was filled with furniture, unable to get crash cart to bedside>moved unnecessary furniture to another room.
Self-Reflection: Reflect on your nursing practice progression.
Met entry to practice competencies # 1, 4, 10, 11, 14, 15, 22, 31, 67, 99
Need to become faster with medication administration: will review common meds the night before clinical, flag my drug book, use my worksheet more appropriately.
Describe how you have incorporated theory into your nursing practice (Knowing through Inquiry)
What did you do well? What is an area for improvement and how will you implement Strategies for this?
I was able to conduct thorough research on any issue that I felt was important. I also found out that inquiring and consulting on technical issues. This enabled me assess my patients and give them the best care. When I was carryout out a test, I was able to see the progress of the patient (Mandell et al.2003). Another important thing in pneumonia is the coding guidelines. Although there exists different inclinations by clinicians on how to make a diagnosis on pneumonia, positive chest x-ray is the most preferred in regards to auditors like; Recovery Audit Contractors, Inspector General’s office coupled with other different auditors. More importantly, coders should be on the look out of the same in records and also they are required to ensure presence of a sign of fluids for the patient undergoing x-ray before the commencement of chest x-ray (Freifeld et al. 2011). Fluids therefore play an important role during the chest x-ray. Additionally, those responsible for coding should check documents for different signs and symptoms, which may include heart rate, respiratory rate and others. Emphasis should also be laid on the importance of filing records of diagnosis of pneumonia by clinicians especially anytime there is a session with the presiding physician.
In conclusion, considerably, for pneumonia patients there should be prompt, suitable and wide-spectrum therapy in more satisfactory dosages to improve usefulness. On the other hand, empiric therapy includes antibiotics from a different category than which the patient is accustomed to in recent treatments. Therefore the beginning of this kind of therapy should given out intravenously and also it can be changed to oral therapy for patients who have responded well to it. Patients with initial-onset disease known to have no risks for multidrug-resilient pathogens are put under different empiric therapy drugs options. Multi-drug resistant pathogens may cause risk factors for pneumonia, denoted by antibiotic therapy which occurs the previous 90 days, hospitalization and also high occurrence of antibiotic resistance present in the community.
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