Hypo Pneumonia - Concept Map PDF

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Pathophysiology

Assessment Data- min. of 3

Hypostatic Pneumonia

(In your own words-cite reference)

Def:Inflammation of the lung parenchyma caused by various microorganisms, including bacteria mycobacteria, fungi, and viruses. Caus Org: Lung decrease Clin. Mani: Productive cough, SOB, vomiting, fever, tachycardia. Pathophys: decrease ventilation of lungs Ref: Thomas Jr, C. F., & Limper, A. H. (2004). Pneumocystis pneumonia. New England Journal of Medicine, 350(24), 2487-2498.

Subjective: 1.productive cough 2. shortness of breath 3. Vomiting

Nursing Diagnosis/Priority Problem #1 (3-part statement)

Ineffective thermoregulation related to infection process as evidence by fever of 101F.

Objective: 1. fever: 101 °F 2. O2 saturation level: 89%

3. Tachycardia

Planning- Short Term Goal #1

1. Patient’s temperature will reduce to 98F by increasing fluid intake and removing excess clothing within 24 hours

Nursing Interventions for Goal #1- min. of 2 1. Assess patient’s vital signs at Least every 4 hours. Rationale: To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment particularly antibiotics and feverreducing drug such as Tylenol administered. 2. Remove excessive clothing, blankets and linens. Adjust room temperature. Rationale: To regulate temperature of the environment and make it more comfortable for the patient.

Nursing Diagnosis/Priority Problem #2 (3-part statement)

Ineffective airway breathing related to inflammation and presence of secretions as evidenced by O2 saturation level of 89%

1. Patient will demonstrate effective breathing techniques within 48 hours by using an incentive spirometer.

Nursing Interventions for Goal #2- min. of 2 1. Administered oxygen therapy and use as

prescribe. Rationale: Using a oxygen therapy continuously every 2 hours

2.

Breathing techniques every 4 hours by using an incentive spirometer. Rationale: Using incentive spirometer helps the expansion of the lungs. Ref: Ackley, B.J., Ladwing, G.B., Flynn, M. M. B., Martinez-Kratz, M.R., & Zanotti, M, (2020). Nursing diagnosis handbook: an evidence- Based guide to planning care. Elsevier.

Ref:

Planning- Short Term Goal #2

Ackley, B.J., Ladwing, G.B., Flynn, M. M. B., Martinez-Kratz, M.R., & Zanotti, M, (2020). Nursing diagnosis handbook: an evidence- Based guide to planning care. Elsevier.

Evaluation- Was the goal met, what evidence would support the goal being met. If goal was unmet, what will you do next? STG #1- Goal was not met. Patient temperature was 100F after 24 hours. Teaching: Having patient to remove excess clothing and increase fluid intake to 2500mL per day. STG #2- Goal was met. Patient O2 saturation level was at 98% after 48 hours....