Case study pn


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Case study pn

  1. 1. Kingdome of Saudi Arabia Ministry of higher education University of hail Critical nursing Case study: Pneumonia Talal Qassem Shapi
  2. 2.  patient's Name(initials): A. H. M Unit:: micu Medical diagnosis: old CVA And pneumonia DEMOGRAPHIC DATA Name : Ayed Hamad Motlaq Al Shammary. Age: 80 yr. Educational level:: NON Occupation: NON Admission date: At 16.30 22635 Sex:: Male Nationality:: Saudi
  3. 3. HEALTH HISTORY HISTORY OF PRESENT ILLNESS: The Patient Has Short Of Breath With Low Level Of Conciseness With Hypertension According To The Pt. Family He Was Bedridden Since 10 Yr. Ago Because Of CVAAnd Yesterday He Has Cough And Short Of Breath And Hypertension . PAST MEDICAL HISTORY: HTN. Bedsores. OLD CVA. Hemiplegia . FAMILY MEDICAL HISTORY: He Had History Of Hypertension And Bed Redden since 10yr ago.
  4. 4. DISEASE PROCESS DEFINITION  Pneumonia: is an inflammatory process involving the terminal airways and alveoli of the lungs caused by infectious agents.
  6. 6. Cause:  Pneumonia is due to infections caused primarily by bacteria or viruses and less commonly by fungi and parasites.
  7. 7. Etiologic Agents  S.aureus  Enterobacteriaceae  P.aeruginosa  Acinetobacter sp.  Polymicrobial  Anaerobic bacteria  Legionella sp.  Aspergillus sp.  Viral
  8. 8. PHYSICAL ASSESSMENT  Inspection  SOB  diaphoresis  chills  respiratory distress  palpation  decreased chest expansion or asymmetry  lymphadenopathy
  9. 9. PHYSICAL ASSESSMENT  percussion  dull  decreased diaphragmatic excursion  auscultation  bronchial breath sounds in periphery  decreased air entry  wheezes and crackles
  10. 10. DIAGNOSTIC TESTS ,PROCEDURES  Chest x-ray shows presence extent of pulmonary disease typically consolidation.  Gram stain and culture and sensitivity test of sputum my indicate offending organism. Blood culture detects bacteremia (bloodstream invasion)occurring with bacterial pneumonia.  Immunologic test detects microbial antigens in serum, sputum and urine.
  11. 11. DIAGNOSTIC TESTS ,PROCEDURES ResultInvestigation very prominent wedge-shape area of airspace consolidation in the right lung CXR Sinus TachycardiaECG 20.09WBC 9.2HGB 413PLT 213CREAT 32BUN
  12. 12. Chest x-ray  A chest X-ray showing a very prominent wedge-shape area of airspace consolidation in the right lung characteristic of bacterial pneumonia.
  13. 13. Vital Signs: SPO2B.PR.RTempH.RTime 96%119/823836.993Admission 94%105/673637.91039AM 96%109/704038.310710AM 97%123/81413810711AM 95%111/773937.98612MD 97%110/803037.91071PM
  14. 14. medication Nursing intervention doseindicationclassificationmedication Give slowly with diluted by NS 1.2mg TID i.v infectionAntibiotic Amoxicillin and clavulanate potassium Augmentin Give slowly with diluted by NS 500mg OD i.v Bacterial infection Antibiotics fluoroquinolones levofloxacin Observe human albumin in blood 100ml OD i.v To replace blood volume loss Human proteinHuman albumin Observe any sing of bleeding 4ml OD sc immobilityAnticoagulant Sodium enoxaparin Clexane Give slowly1g QID i.v Pain fever Pain reliever acetaminophen paracetamol
  15. 15. Nursing process Assessment  With unproductive cough  With wheezes and crackles auscultated on left lower lung field.  Presence of clear watery discharge from her nose.  Short of breath.
  16. 16. Nursing Diagnosis  Ineffective airway clearance related to presence of secretions secondary to pneumonia.
  17. 17. goal  Short Term  After 3-4 hours of nursing interventions, the patient’s respiration will improve and difficulty of breathing will be relieved.  Long Term  After 3 – 4 days of nursing interventions, the patient will maintain a patent airway.
  18. 18. NURSING INTERVENTIONS  Monitor and record V/S.  Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds.  Assist patient to change position every 30 minute  Provide health teachings regarding effective coughing and deep breathing exercise.  Encourage to increase fluid intake.  Administer meds as ordered.
  19. 19. Evaluation  Short Term:  After 3-4 Hours Of Nursing Interventions, The Patient’s Respiration Have Improved goal is met.  Long Term:  After 3 – 4 Days Of Nursing Interventions, The Patient Have Been Able To Maintain A Patent Airway goal is met.
  20. 20. Assessment  Flushed Skin.  Skin Warm To Touch.  Temperature Higher Than 37.6c  Dehydration.
  21. 21. Nursing Diagnosis  Risk For Infection Rt Inadequate Primary Defenses.
  22. 22. goal  Short term  After 4°h of nursing intervention the pt.'s temperature will drop from 38.4 °C to 37 °C  Long term:  After 2-3 days of nursing intervention the patient will be free from hyperthermia.
  23. 23. NURSING INTERVENTIONS  Give antipyretic as order.  Assess skin temperature and color.  Monitor WBC count.  Encourage fluid intake orally or intravenously as ordered.  Measure intake and output.
  24. 24. Evaluation  Short term:  After 4h° of nursing intervention the pt.'s temperature drop from 38.4 °C to 37.4 °C or lower. goal is met  Long term:  After 2-3 days of Nursing intervention , the patient free from hyperthermia. Goal is met.
  25. 25. PATIENT EDUCATION  Eating Well Balanced Meals  Adequate Rest  Avoiding Upper Respiratory Infections Or Getting Promptly Treatment For Early Symptoms  Drinking Large Amounts Of Fluids To Thin Secretions And Replace Fluid Loss  Avoiding Spread Of Infections By Washing Hands And Properly Dispose Of Tissues  Avoid Smoking; Perform Coughing And Deep Breathing exercises.