Harry Smith, 70 years of age, is a male patient who is admitted to the medical-surgical unit with acute community-acquired pneumonia.
NURSING CARE PLAN RUBRIC
Case Study, Chapter 23, Management of Patients With Chest and Lower Respiratory Tract Disorders
1. Harry Smith, 70 years of age, is a male patient who is admitted to the medical-surgical unit with acute community-acquired pneumonia. He was diagnosed with paraseptal emphysema 3 years ago. The patient smoked cigarettes one pack per day for 55 years and quit 3 years ago. The patient has a history of hypertension, and diabetes controlled with oral diabetic agents. The patient presents with confusion as to time and place. The family stated that this is a new change for the patient. The admission vital signs are as follows: blood pressure 90/50 mm Hg, heart rate 101 bpm, respiratory rate 28 breaths/min, and temperature 101.5°F. The pulse oximeter on room air is 85%. The CBC is as follows: WBC 12,500, platelets 350,000, HCT 30%, and Hgb 10 g/dL. ABGs on room air are pH 7.30, PaO2 55, PaCO2 50, HCO3 25. Chest x-ray results reveal right lower lobe consolidation, presence of apical bullae, flattened diaphragm, and a small pleural effusion in the right lower lobe. Lung auscultation reveals severely diminished breath sounds in the right lower lobe and absence of breath sounds at the base. The breath sounds in the rest of the lungs are slightly decreased. The patient complains of fatigue and shortness of breath and cannot finish a short sentence before the respiratory rate increases above the baseline and his nail beds and lips turn a bluish tinge and the pulse oximetry decreases to 82%. The patient is diaphoretic and is using accessory muscles. The patient coughs weakly, but he does not raise any sputum. (Learning Objective 3)
a. What nursing assessment findings support the diagnosis of pneumonia?
b. What diagnostic findings support the diagnosis of pneumonia?
c. What NANDA nursing diagnoses should the nurse formulate for the patient?
d. What goals should the nurse develop for the patient?
e. What overall interventions should the nurse provide?
1) Definition of the medical diagnosis
etiology/pathophysiology
2) Common signs and symptoms
3) Potential complications
4) Head to toe physical assessment you are to write one….
5) Diagnostic and lab studies
normal values
expected abnormalities
6) ALL NANADA Nursing diagnoses
https://nurseslabs.com/nursing-diagnosis/
https://ar.israa.edu.ps/uploads/documents/2020/02/4gcM0.pdf
7) Develop 3 NANDA priority nursing diagnoses
8) State a patient plan AND goal for each of the
3 priority nursing diagnosis
9) Write interventions for each of
3 priority nursing diagnosis
10) Write scientific rationales for you you
interventions
11) Write evaluation of your interventions
your plan or make changes
12) List of typical medications
category
usual dosage
side effects
patient teaching
