Sepsis Related to Aspiration Pneumonia , with Current Condition of Cerebral Palsy and Developmental Delay

Patient description

The patient was admitted to the hospital from home as result of suffering from Sepsis-related to aspiration pneumonia. According to Balady et al. (2007), pneumonia is one of the leading infections, which causes the death of most adult within the different population, and it affects majorly the lungs which are made up of alveoli when an individual is breathing. The patient was diagnosed and found to be suffering from pneumonia which caused mainly by bacteria which is transferred through the air while he was traveling together with infected persons in the environment where he lives. One of the symptoms of the infection as observed from the patient is inflation of the air sacs found in the patient lungs after which the alveoli are filled with fluids as well as pus thus interferes with the natural gases exchange taking place within the lungs. Other symptoms that the patient possesses include a cough, fever, chills, and breathing difficulties.

Current medical condition of the patient

The client has been examining to have cerebral palsy as he is also alert and nonverbal. Most of the symptoms shown by the patient currently are characteristics of a person who has been affected by the bacteria causing pneumonia. As the patient continues to go through treatment, his condition continues to get better day by day. There are various attempts made by the doctor for ensuring the patient get better as fast as possible. For example, restricting or putting on holds the fluid that the patient take is a step taken to ensure the Patient PIVV line is reinserted back to normal (Watson, 2007).

The priority system assessment

This indicates various findings and rationale for the findings regarding the conditions of the patient. The first assessment done to the patient is a respiratory assessment. This is associated with the ineffective airway clearance that is accompanied by excessive secretion along the respiratory track. For the patient suffering from pneumonia, a productive cough is experienced as one of the client symptoms. Interventions for pain management includes administration of medications such as Hydromorphone IV, teaching the patient how to manage pain such as deep breathing exercise and proper positioning if he can. Retained secretions can obstruct airways, leading to an impaired gas exchange that causes pain during inspiratory and expiratory. Rationale: The bacterial pneumonia found in most adults contains risks, which cause the adverse cardiac activities for example heart failure, and heart attacks this contributes significantly to mortality. The pain experienced by the patient is evidenced by the changes that occur in heart rate. Inventions required in the clinical treatment process. Various adjustments need to be made in the medical sector as clinicians make the effort of ensuring patients get required medical attention and drugs. Some of which are listed below. There is need to come up with ways of encouraging patients to get rest as well as avoiding over relaxation which can cause an increase in the number of symptoms they experience while they are they are under medication (Kuiper & Pesut, 2004). Since the patient is examining to suffer from pneumonia, improving on the smoothness level of the patient airway patency is necessary. Secretion is one of the symptoms that the infection is characterized with and to fasten the recovery rate, there is need to ensure the secretion interfere retained in its initial conditions (Kuiper & Pesut, 2004). This way breathing efficiency of the patients has increased hence the secretion clearance as well as volume expansion is promoted.

Laboratory concerns based on the diagnosis values

The patient is likely to have anemia based on the lab values obtained (iron deficiency). That is the patient has not been taking balance diet, which does not contain iron (Hgb- 95g/L-Low). Therefore, to ensure that the patient has a strong immune system the oxygen carrying capacity needs to improve for efficient breathing system (Winters, 2013). Medical history of the patient is a necessary clarification that all qualified physicians or doctors must inquire before recommending any further treatment for patients. Similar, carrying out physical exams are important which include auscultating the lungs to check for the abnormal bubbling as well as crackling sounds, which are symptoms of pneumonia. The physician or nurses started to ask about the medical history as well as doing a physical exam, including auscultating of the lungs for checking the abnormal bubbling experienced by the patient and the crackling sounds which are symptoms of pneumonia. Upon suspecting pneumonia, the doctor will recommend the tests listed below: Blood Tests: These are used for the purpose of confirming an infection as well as identifying specific organisms/pathogens, which causes the infection. They found client has low hemoglobin and high PT. Chest X-ray: A chest x-ray is the best tool for diagnosing pneumonia. It is used to determine the extent as well as location of the disease. The patient was examine through chest X-RAY to confirm whether he had lung abscess, fluids or air in his lungs. The X-RAY showed fluid in his right lower lobe. They inserted chest tube on his right chest to drain off fluids. Sputum Test: is a sample of fluid taken from the patient lungs after a deep cough by the patient and carry out its analysis to identify the pathogen causing the disease. Revealed my patient had bacterial pneumonia. CT scan: when the infection is not clearing faster as projected, the doctor will recommend an alternative testing which is a chest CT scan to be able to obtain an image of the lungs, which is more detailed. Pleural fluid culture:  is the liquid sample, which is taken through putting a needle in between the ribs of an individual starting from the pleural region as well as carrying out an analysis to assist in identifying the infection type. Incorporation of theory into the nursing practice Application of knowing via inquiry, which is termed to be empirical, personal as well as aesthetic, is used. The application of the science of knowing assist in identifying the patients normal and most sensitive signs making it easier to predict the possible result of diagnosis thus faster medical recommendations. Similarly, science knowing allows the clinicians to have a proper understanding of the side effects that the drugs they prescribed to the patients are likely to pose on their health (Winters, 2013). An effective introduction to patients needs the clinicians to have the ethical way of knowing. Ethical way of knowing provide the medical specialist with the opportunity to acquire knowledge in their field of study and master all procedures which are involved in treating patients in the clinics. Demonstration of safe patient care and the unsafe situations observed in the medical environment Ensuring safety in the medical facilities or health care clinics is essential, as most of the operations need to be carried out faster based on different conditions that are experienced by patients. One of the safe patient cares I employed to ensure their safety is keen monitoring and checking of the equipment used for their protection like oxygen and Foley cater (Landers, 2000). Removing obstacles in the clinic environment is another safe patient care practice that I employed in ensuring the patient is well-taken care off/safe. Other safety measures are put in place during treatment of the patient is cleaning of the equipment used during diagnosis after each procedure. Safe nursing practices is a step in ensuring that one gains personal nursing progression, that is the progress of competencies as well as being able to learn the plan goals (Zwarenstein, et al. 2009). This involved demonstrating a professional presence and model behavior while handling patients. This is possible through pear introduction and learning how to interact effectively with the patients in every medical environment (Zwarenstein, et al. 2009). Application of relevant assessment tools as well as techniques while consulting different patients and different health care providers is a safe nursing practice recommended for good patient protection. The BP machine and telescope were used effectively in assessing the bow sound produced by the patient suffering from pneumonia, and this ensures the feelings of the patient are recorded appropriately. After diagnosis and treatment of the patient, there are various factors, which act as barriers to the discharge of the patient. Some of which are listed below. Development of nosocomial infections such as C-difficult or MRSA, associated with hospitalization. Persistence of pneumonia symptoms despite a course of antibiotics. Fortunately, the patient had a good response to treatment within 48 hours of antibiotic administration. The Doctor even removed the chest tube, meaning the fluid in the lungs were not visible anymore (Kolanowski, et al., 2011). Development of complications indicated by an increase in temperature with growing cough, fremitus, and adventitious breath echoes on auscultation of the lungs, confusion and variations in cognitive status. Misperception might be related to hypoxemia, fever, dryness sleep deficiency or emerging sepsis (Kolanowski, et al., 2011). Development of complications is evidenced by the increase in temperatures as well as cough increased as well as well cognitive status. Some of the confusions experienced are related to hypoxemia, fever, dehydration and developing sepsis

Areas of improvement

One of the challenges I faced during my early days of my clinical was mixed emotions of nervous as well as existence. Because this was my first medical unit association with others after several years of study (Watson, 2007). For one to be able to learn new things in the medical field, for example, checking the IV for preventing complication like filtration, there is need to put more commitments. Working in a various hospital environment with modernized technology is an important factor that an individual practicing nursing needs to put into consideration. Being ready to assist others is another character that needs adjustment for one to cope up with the nursing assistance needs in health care centers.

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