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Kingdome of Saudi Arabia Ministry of higher education University of hail Critical nursing Case study: Pneumonia Talal Qassem Shapi

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Page 1: Case study pn

Kingdome of Saudi Arabia

Ministry of higher education

University of hail

Critical nursing

Case study: Pneumonia

Talal Qassem Shapi

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patient's Name(initials): A. H. M

Unit:: micu

Medical diagnosis: old CVA And pneumonia

DEMOGRAPHIC DATAName : Ayed Hamad Motlaq Al Shammary.

Age: 80 yr.

Educational level:: NON

Occupation: NON

Admission date: At 16.30 22\6\35

Sex:: Male

Nationality:: Saudi

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HEALTH HISTORYHISTORY 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

CVA And 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.

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DISEASE PROCESSDEFINITION

Pneumonia: is an inflammatory process involving the terminal airways and alveoli of the lungs caused by infectious agents.

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SING AND SYMPTOMS

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Cause:

Pneumonia is due to infections caused primarily by bacteria or viruses and less commonly by fungi and parasites.

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Etiologic Agents

S.aureus

Enterobacteriaceae

P.aeruginosa

Acinetobacter sp.

Polymicrobial

Anaerobic bacteria

Legionella sp.

Aspergillus sp.

Viral

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PHYSICAL ASSESSMENT

Inspection

SOB

diaphoresis

chills

respiratory distress

palpation

decreased chest expansion or asymmetry

lymphadenopathy

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PHYSICAL ASSESSMENT

percussion

dull

decreased diaphragmatic excursion

auscultation

bronchial breath sounds in periphery

decreased air entry

wheezes and crackles

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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.

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DIAGNOSTIC TESTS ,PROCEDURES

ResultInvestigationvery prominent wedge-shape area of

airspace consolidation in the right lung CXR

Sinus Tachycardia ECG

20.09WBC

9.2HGB

413PLT

213CREAT

32BUN

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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.

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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

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medicationNursing

interventiondoseindicationclassificationmedication

Give slowly with diluted by NS

1.2mgTIDi.v

infectionAntibioticAmoxicillin and

clavulanatepotassium

Augmentin

Give slowly with diluted by NS

500mgODi.v

Bacterial infection

Antibioticsfluoroquinolones

levofloxacin

Observe human albumin in

blood

100mlODi.v

To replace blood volume

loss

Human protein Human albumin

Observe any sing of bleeding

4mlODsc

immobilityAnticoagulant Sodium

enoxaparin

Clexane

Give slowly 1gQIDi.v

Painfever

Pain relieveracetaminophen

paracetamol

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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.

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Nursing Diagnosis Ineffective airway clearance related to presence of

secretions secondary to pneumonia.

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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.

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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.

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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.

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Assessment

Flushed Skin.

Skin Warm To Touch.

Temperature Higher Than 37.6c

Dehydration.

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Nursing Diagnosis

Risk For Infection R\t Inadequate Primary Defenses.

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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.

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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.

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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.

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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.

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