nursing report of pneumonis patient

Nursing Diagnosis: Hyperthermia related to the disease process of bacterial pneumonia as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, and profuse sweating. Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.

Full Answer

What are the Nursing Diagnoses Related to the patient with pneumonia?

Based on the information gained through the nursing assessment the nursing diagnoses related to the patient with pneumonia include: Nurses set to achieve goals in conjunction with the patient. These goals are based on the outcome of assessments and the diagnoses. Maintaining adequate hydration is essential.

What is included in the pneumonia nursing care guide?

This guide has pneumonia nursing care plans and nursing diagnosis, nursing interventions, and nursing assessment for pneumonia.

What are the nursing interventions for the management of pneumonia?

These nursing interventions, if implemented appropriately, would result in the achievement of the goals of the management of pneumonia. Removal of secretions. Secretions should be removed because retained secretions interfere with gas exchange and may slow recovery. Adequate hydration of 2 to 3 liters per day thins and loosens pulmonary secretions.

What are the risk factors for pneumonia in nursing?

During the nursing assessment, you inform your patient on some of the risk factors that may have increased their chances of them contracting pneumonia. The common risk factors being • COPD- Chronic Obstructive pulmonary disease. • Hospital stays; ironically, hospital stays increase your chances of contracting pneumonia.

How do you document a patient with pneumonia charting?

Pneumonia [Documentation Suggestions]Describe clinical signs and symptoms (e.g., fever, chills, cough, dyspnea, tachypnea, crackles or rales, etc.).Note radiological and laboratory findings - include rationale for disagreement with any findings (e.g., negative chest xray, culture, etc.).More items...

What is nursing diagnosis for pneumonia?

Nursing Diagnosis: Ineffective Breathing Pattern related to decreased lung expansion secondary to pneumonia as evidenced by a respiratory rate of 22, usage of accessory muscles, and labored breathing.

What assessment should the nurse do on a patient with pneumonia?

Physical assessment. Assess the changes in temperature and pulse; amount, odor, and color of secretions; frequency and severity of cough; degree of tachypnea or shortness of breath; and changes in the chest x-ray findings. Assessment in elderly patients.

How do you assess a patient with pneumonia?

AdvertisementBlood tests. Blood tests are used to confirm an infection and to try to identify the type of organism causing the infection. ... Chest X-ray. This helps your doctor diagnose pneumonia and determine the extent and location of the infection. ... Pulse oximetry. ... Sputum test.

What are the 4 types of nursing diagnosis?

There are 4 types of nursing diagnoses: risk-focused, problem-focused, health promotion-focused, or syndrome-focused.

How do you write a nursing diagnosis?

A nursing diagnosis has typically three components: (1) the problem and its definition, (2) the etiology, and (3) the defining characteristics or risk factors (for risk diagnosis). BUILDING BLOCKS OF A DIAGNOSTIC STATEMENT. Components of an NDx may include problem, etiology, risk factors, and defining characteristics.

How do you document lung assessment?

Documentation of a basic, normal respiratory exam should look something along the lines of the following: The chest wall is symmetric, without deformity, and is atraumatic in appearance. No tenderness is appreciated upon palpation of the chest wall. The patient does not exhibit signs of respiratory distress.

What are some nursing interventions for pneumonia?

Nursing InterventionsAdminister oxygen as prescribed.Monitor respiratory status.Monitor for labored respirations, cyanosis, and cold and clammy skin.Encourage coughing and deep breathing and use of incentive spirometer.Position client in semi-Fowler position to facilitate breathing and lung expansion.More items...

What are some expected assessment findings for pneumonia?

Assessment findings include:Inspectionincreased respiratory rate increased pulse rate guarding and lag on expansion on affected side children with pneumonia may have nasal flaring and/or intercostal and sternal retractionsPalpationchest expansion decreased on involved side tactile fremitus is increased2 more rows

What are three 3 physical assessment findings that are noted with the development of pneumonia?

Physical examination of patients with pneumonia is usually remarkable for: shortness of breath, cough, fever, and difficulty breathing.

What are the three physical assessment findings that are noted with the development of pneumonia?

Physical findings may include the following: Adventitious breath sounds, such as rales/crackles, rhonchi, or wheezes. Decreased intensity of breath sounds. Egophony.

What is the nursing diagnosis for infection?

Risk for infection is a NANDA nursing diagnosis that involves the alteration or disturbance in the body's inflammatory response, which allows microorganisms to invade the body and cause infection. It is a common problem in people with low immune system.

What are nursing diagnosis for respiratory?

Diagnoses. Commonly used NANDA-I nursing diagnoses for patients experiencing decreased oxygenation and dyspnea include Impaired Gas Exchange, Ineffective Breathing Pattern, Ineffective Airway Clearance, Decreased Cardiac Output, and Activity Intolerance.

What are the nursing interventions for pneumonia?

Nursing InterventionsAdminister oxygen as prescribed.Monitor respiratory status.Monitor for labored respirations, cyanosis, and cold and clammy skin.Encourage coughing and deep breathing and use of incentive spirometer.Position client in semi-Fowler position to facilitate breathing and lung expansion.More items...

Is pneumonia a medical diagnosis?

To diagnose pneumonia, your healthcare provider will review your medical history, perform a physical exam, and order diagnostic tests such as a chest X-ray. This information can help determine what type of pneumonia you have. Treatment for pneumonia may include antibiotic, viral, or fungal medicines.

Nursing Diagnosis

Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by shortness of breath, low SPO2, and bacteria found in sputum culture.

Nursing Diagnosis

Ineffective airway clearance related to mucous production as evidenced by tachypnea, crackles, and consolidations on x-ray

Nursing Assessment

The patient reports feeling “very hot one minute and very cold the next minute.”

Nursing Diagnosis

Ineffective thermoregulation related to lung infection as evidenced by chills and fever

Nursing interventions with rationales for Ineffective thermoregulation

To conclude, we created scenario-based three sample nursing care plans for pneumonia. This nursing care plan includes nursing assessment, NANDA nursing diagnosis, expected outcome, and nursing interventions with rationales.

What is the cause of pneumonia?

Pneumonia is caused by a bacterial or viral infection that is spread by droplets or by contact and is the sixth leading cause of death in the United States.

What are the two types of pneumonia?

Types of Pneumonia. There are two types of pneumonia: community-acquired pneumonia (CAP), or hospital-acquired pneumonia (HAP) or also known as nosocomial pneumonia. Pneumonia may also be classified depending on its location and radiologic appearance.

What happens if you leave pneumonia untreated?

If left untreated, pneumonia could complicate to hypoxemia, respiratory failure, pleural effusion, empyema, lung abscess, and bacteremia. Nursing care plan (NCP) and care management for patients with pneumonia start with an assessment of the patient’ medical history, performing respiratory assessment every four (4) hours, physical examination, ...

What is ineffective airway clearance?

Ineffective Airway Clearance is a common NANDA nursing diagnosis for pneumonia nursing care plans. This diagnosis is related to excessive secretions and ineffective cough or nonproductive coughing. Inflammation and increased secretions in pneumonia make it difficult to maintain a patent airway.

What is the first step in the assessment of pneumonia?

1. Palpation. Palpation is a process where the nurse physically examines the patient. This is the first step of its assessment feeling the patient using your hands as a nurse. Breathing difficulties can be detected during this step depending on the pneumonia intensity and how far it has spread through your lungs. 2.

How many breathes per minute for pneumonia?

When pneumonia is mild in infants, the temperature tends to be <38.50 C RR< 50 breathes per min. The recession is also mild, and feeding pattern is usually undisturbed. If the condition is severe temperatures may go as high as 40o C RR>30 breathes per min. The recession rate is also, and the child does not feed.

Why is it important to know the first step of a nursing procedure?

In nursing procedures, this is always the first step. In this case, it is vital for detecting the development of pneumonia and establishing medical treatment. It is an inflammation of airspaces in the lungs (lung parenchyma), which is associated with alveolar edema and congestion or obstruction of the bronchioles.

Why is walking pneumonia contagious?

The most common cause of it is the Influenza virus, A and B. Other causes include Respiratory Syncytial virus (RSV), Rhinoviruses, Adenoviruses, Coronaviruses, and Parainfluenza viruses. It is one of the most contagious types of pneumonia. It is also referred to as “walking pneumonia” owing to how easily it spreads.

What are the two types of pneumonia?

Types of Pneumonia. • Bacterial pneumonia. It is divided into two kinds; Community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HAP). The most common culprit of CAP is the Streptococcus pneumoniae.

Why do people get pneumonia?

It is among the rarest forms of pneumonia. It is caused by fungi that find their way into the lungs. People with functional immune systems seldom end up contracting it since the body can detect and fight the fungi long before it reaches the lungs.

What is the most common method used in the assessment of a patient's history?

The process of listening to breathe sounds using an assessment tool known as the stethoscope. This is the most common method used in its assessment. Patient’s History Medical Assessment. The patient’s history gives a guideline on what may have led to the infection.

What is pneumonia in nursing?

So let’s recap quickly. Pneumonia is an inflammatory process in the lungs that involves fluid or pus filling the alveoli and preventing proper gas exchange.

What are the symptoms of pneumonia?

Bacterial pneumonia is more severe than the others, but all pneumonias share some common symptoms like chills, rhonchi, wheezes, and a decreased SpO2. We treat them with antibiotics, antipyretics, and analgesics, plus we make sure they receive their vaccines and encourage fluids to thin out secretions.

Why is infection control important in nursing?

And infection control is a top priority to prevent pneumonia in the first place or to prevent it from spreading and treat the current infection. Make sure you check out the care plan attached to this lesson to see more specific nursing interventions. So let’s recap quickly.

What causes a pulmonary inflammatory response?

Pathophysiology: Pneumonia is an inflammatory response. This can be caused by an infection or things like aspiration where fluid gets into the lungs, which causes the alveoli to fill with fluid or pus. When the alveoli are filled with fluid or pus then proper gas exchange does not occur as well.

How to prevent pneumonia?

Prevention is the key to protecting against infection. Good hygiene practices. Good hygiene practices, including following hand hygien e principles such as regular hand washing and the use of alcohol-based hand sanitizer, will help protect against respiratory infections that may lead to pneumonia. Smoking cessation.

What is hospital acquired pneumonia?

Hospital-Acquired Pneumonia (HAP) An acute lower respiratory tract infection that is acquired at least 48 hours after admission to the hospital and is not incubating at the time of admission (Forest 2020). Also referred to as nosocomial pneumonia.

What is the best treatment for pneumonia?

Oral antibiotics are most commonly used to treat bacterial pneumonia. In the absence of the causative bacteria being identified, empirical antibiotics or antibiotics are chosen to treat the likely pathogen causing bacterial pneumonia are often used.

What is pneumonia in the air?

Pneumonia is defined as inflammation in one or both lungs, with the presence of consolidation and exudation. Inhaling infected droplets in the air from a cough or sneeze of an infected person is the mechanism in which pneumonia is commonly spread.

How long does it take to recover from pneumonia?

Once appropriate pharmacologic treatment is commenced patients will generally recover in around seven to 10 days.

Why is a thorough nursing assessment necessary?

A thorough nursing assessment is necessary to establish nursing diagnoses, plan nursing care, set realistic goals, implement nursing interventions and to enable the evaluation process . This article discusses the nursing management of pneumonia and the associated disease process.

How does physical therapy help with pneumonia?

A balanced diet, including adequate servings of fruit and vegetables, promotes recovery from illness. Chest physical therapy benefits mucus transport and assists in the expectoration of secretions. Adherence with the prescribed medication regimen is key to recovery and preventing resurgence of pneumonia.

What are the symptoms of pneumonia?

The​​ patient presented with symptoms of a cough with yellow sputum, shortness of breath, hypoxemia, low grade temperature, mild tachypnea,​​ borderline tachycardia,​​ and fatigue. ​​ Per​​ Bartlett (2018), these symptoms are suggestive of pneumonia, and considering that the patient lives at home, this would be considered a community acquired pneumonia (CAP). ​​ Bartlett also states that additional typical findings of a CAP include pleuritic chest pain, as well as nausea, vomiting, diarrhea, chills, and rigors, so these items would be inquired about in the history of present illness, review of systems, and physical examination. ​​ I would also inquire if the patient were around any sick individuals or has had any issues swallowing (aspiration) that may point towards an etiology​​ (Bartlett, 2018). ​​​​

What are the symptoms of a CAP?

Bartlett also states that additional typical findings of a CAP include pleuritic chest pain, as well as nausea, vomiting, diarrhea, chills, and rigors, so these items would be inquired about in the history of present illness, review of systems, and physical examination.

What is the most common cause of respiratory alkalosis?

Theodore (2017) states that the most common cause of respiratory alkalosis is hyperventilation. Given that the​​ patient is slightly tachypneic and​​ likely compensating for being​​ hypoxemic, he could be​​ lowering his carbon dioxide level​​ through overexcretion in the alveoli of the lungs ​​ (Theodore, 2017).

What Is Pneumonia?

Classification

Pathophysiology

Epidemiology

Causes

Clinical Manifestations

Prevention

Complications

• Pneumonia has several complications if left untreated or the interventions are inappropriate. These are the following complications that may develop in patients with pneumonia. 1. Shock and respiratory failure.These complications are encountered chiefly in patients who have received no specific treatment and inadequate or delayed treatment. 2. Pleu...

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Assessment and Diagnostic Findings

Medical Management