Pneumonia Case Study

 

Mr. Smith is a 78-year-old male African American who lives at home with his wife. He was brought to the hospital because was experiencing shortness of breath, chills, and chest pain when he inhales. He stated that he started to cough about a week ago, so he started to take over the counter cough and cold medication because he thought that he just had a common cold because it is beginning to get cold outside, but the cough only got worse. The cough was productive, the sputum was thick, yellow, and blood tinged. Upon examination his respiration rate was 28 breath per minute, shallow and labored, heart rate 122 bpm, blood pressure 149/92, temperature 102.1˚F and oxygen saturation was 88%. This patient was also using accessory muscles to breath. Upon auscultation there were crackles and wheezing, and absent breath sounds in right middle lobe. During the assessment the patient stated that he was not able to eat or drink much because he felt weak and did not have much of an appetite. The patient’s history revealed that he was a smoker for about 30 years, but he quit about 10 years ago. He also has mild hypertension which is controlled with medication, diabetes, a tonsillectomy in his 20’s, and he is also allergic to penicillin and morphine. The patient also stated that he is not up to date with his immunizations because he believes that it Is all just a scam and he declined to take the flu and pneumonia vaccines when they were recommended by his primary care physician. Based on the findings of the assessment it appears the patient might have pneumonia. To treat the patient’s symptoms, the physician ordered 2 liters of humidified oxygen via nasal canula stat, a bronchodilator, Tylenol via IV and a broad-spectrum antibiotic while waiting for the results of the diagnostic tests. To confirm the perceived diagnosis and treat the patient appropriately, then physician ordered a chest radiography to detect the affected areas of the lungs, an arterial blood gas analysis, sputum culture and sensitivity test, and a complete blood count with differential. The chest x-ray revealed consolidation in the right middle lobe of the lungs, while the rest of the right and left lungs were clear. His white blood cell count was elevated which is an indication that an infection is present. The culture and sensitivity test revealed the presence of the gram positive, beta-hemolytic bacteria streptococcus pneumoniae, and which antibiotics the bacteria are most sensitive to. His hemoglobin was also low, it was 9.5g/dL. The arterial blood gas was also abnormal, pH =7.42, PaCO2=26, HCO3=26, PaO2 =54. The diagnostic test confirmed that the patient had pneumonia and the appropriate treatments were administered. Information written in this paper should be relevant to the case study above! Question 1,2, and 3 are the questions that needs to be answered based on the case study above. THESE CAN BE FOUND BELOW 1. Relevant clinical assessment with laboratory findings of the patient’s presenting values and normal values as well as other relevant tests for this medical condition WITH EXPLANATIONS OF THE TESTS (#3 person) 11% 2. Current medical treatment and clinical management strategies including disease specific medications. AT LEAST TWO EXAMPLES OF MEDICATIONS WITH GENERIC NAMES, USUAL DOSES, AND SIDE EFFECTS THAT PATIENTS MUST BE TAUGHT. MEDICAL TREATMENT INCLUDES DIET AND ACTIVITIES (# 3 person) 13% 3. FOUR ACTUAL (NO “RISK FOR”) Nursing diagnosis statements. (3-part statement – (a) nursing diagnosis, b) related factor(s), c) presenting signs/symptoms that provide the evidence for each nursing diagnosis). The Nursing diagnosis should reflect the patient’s condition when he/she came to the provider. IN OTHER WORDS, THE PATIENT SHOULD ACTUALLY MANIFEST THESE NURSING DIAGNOSIS SIGNS/SYMPTOMS IN THE CASE STUDY. Formulate FOUR nursing interventions for EACH NURSING DIAGNOSIS, with scientific rationales for EACH intervention – A TOTAL OF 16 INTERVENTIONS. (What the nurse implements that would effect a change in the patient’s condition. INTERVENTIONS DO NOT INCLUDE “NOTE,” “ASSESS,” “MONITOR,” “CHECK,” “DETERMINE” “OBSERVE” “WEIGH” OR ANY VARIATION OF THOSE WORDS these are Assessments. Evidence should be in the case study (EACH PERSON DOES ONE NURSING DIAGNOSIS – EVERYONE) 18% Medical diagnosis is based on physiological and medical condition and nursing diagnosis is based on the person’s response or alteration to that condition. 4. Nursing diagnosis with 4 intervention: The nursing diagnosis for this paper is Ineffective airway clearance- with 4 interventions – b) related factor(s), c) presenting signs/symptoms that provide the evidence for each nursing diagnosis). The Nursing diagnosis should reflect the patient’s condition when he/she came to the provider. IN OTHER WORDS, THE PATIENT SHOULD ACTUALLY MANIFEST THESE NURSING DIAGNOSIS SIGNS/SYMPTOMS IN THE CASE STUDY. Instructions on how to write the paper This will be strictly enforced. Please go to the writing center EARLY if you believe you need help in this area. Bullets should begin at the 1 inch margin. Double, triple, quadruple spacing or higher will result in substantial reduction in grade. COVER AND REFERENCE PAGES ARE SEPARATE FROM THE 6 – 8 PAGE PAPER Paper should synthesize information from a peer reviewed NURSING Journal obtained from the data base CINAHL for the nursing article related to this condition. 1 inch margin left and right side; 1 inch top and bottom; 1.5 line space; no space before or after paragraph; 12 point font (Times New Roman). SOURCES CITED SHOULD NOT INCLUDE encyclopedias, Merck manual, medscape, Medline, WebMD, Mayo clinic.org, Centers for disease control, Wikipedia, or other non nursing sources including WEBSITE MEANT FOR TEACHING THE PUBLIC. If using internet sites other than for the nursing articles – Only ONE online website may be cited. ALL OTHER ONLINE REFERENCES SHOULD HAVE AN AUTHOR’S NAME AND INFORMATION ABOUT THE JOURNAL OR BOOK FROM WHICH THE ARTICLE WAS TAKEN. No reference should be older than ten years. DO NOT CITE A PROFESSOR’S LECTURE.

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