Clinical Updates about Pneumonia Patients

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:

1. a) What is their admission diagnosis – briefly describe what brought patient to hospital and demonstrate your understanding of the diagnosis. Admitted to medicine / Surgical with Pneumonia. “Pneumonia is an infection of the lungs in one or both lungs. It can be caused by bacteria, viruses, or fungi. Bacterial pneumonia is the most common type in adults. Pneumonia causes inflammation in the air sacs inyours lungs, which are called alveoli. The alveoli filled with fluid or pus, making it difficult to breath”

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.

38. b) What is current medical condition–Client presented of fever 38.5C once , dry cough , crackles adventitious sounds , shortness of breath, right chest pain ,X-RAY and CT SCAN done during admission , chest tube was inserted to right chest with local anesthesia  5 days ago  , scanty clear yellow fluid drained off connected to extension tube and water sealed drained system. Puncture site intact, no oozing, dressing with stat lock, gauze, prima pore. Client is in in contact /droplet precautions dueto gram positive bacteremia that invade his lungs that caused infections.  With IV fluids ongoing of  9 NS  with the rate of 125ml/hr on his  left  metacarpal dry and intact iv site
39. c) Co-morbidities/past medical history – indicate knowledge of significant ones listed and implications for care. Client had a history of mild ETOH.
40. d) Social history – where does patient come from (home, nursing home etc), and who is their support system? Client was at home when he  passed out.
41. e) Cultural humility-how did you integrate the cultural practices of your patient? What other spiritual care did you provide? Client was polite and cooperative when I obtaining some information. Client taught not to say sorry, unless I did heavy mistakes.
42. f) Priority nursing assessments- indicate your priority systems assessed –indicate findings and provide rationale for whether abnormal or normal.

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.

Priority nursing assessment:

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: showed an acute infectious disease process.

1. Cardiovascular: Client has an elevated blood pressure 155/89, PR- 105/min

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.

1. g) Interventions required – Chest tube to drain off the fluids from the right chest, dressings on the puncture sites and I.V sites to prevent infection,  PPE contact/droplet  precautions to prevent spread of infection,IV antibiotics Azithromycin and Ceftriaxone  dressings,
2. h) Lab Values –relate significant lab values to current diagnosis/medical condition and provide rationale as well as any significant concerns.
3. a) Hgb- 95g/L LOW
4. b) PT-17.0 ( 12.0-14.6)-HIGH
5. c) INR-1.4 (0.9-1.1) H
6. i) Diagnostics – incorporate knowledge of significant diagnostic findings to current diagnosis/medical condition. Pneumonia – conducted a physical exam, chest x-ray, chest CT, chest ultrasound, and needle biopsy of the lung to help diagnose the condition.

List all scheduled medications for this patient and relate to patients current condition or to a past medical history condition.

Communication:

1. a) Indicate any unique or special communication techniques for this patient.
2. b) Describe patient teaching performed and patient/family response.
3. c) Indicate any collaborated communication with health care team (daily rounds, physician etc)
4. d) Describe your therapeutic relationship with this patient/family.
5. e) What are the barriers to discharge and what is your role to ensure discharge process is

• By providing assurance and reorienting patient to a person , place and time.
• Through regular checks concerning pain and comfort level
• Through explicit explanation of procedures before they are done to enable patient take part in care.

How did you integrate ethical practice into your care?

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?

• Focused on the Caritas Process #5 “Being present to, and supportive of, the expression of positive & negative feelings.

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.

Progress of competencies and learning plan goals

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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