Kenneth Bronson Nursing Care Plan PDF

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Kenneth Bronson Nursing Care Plan...

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Pace University Lienhard School of Nursing Nursing Care Plan Name: Riley Leonard Pt's Initials: K.B. Age: 27 Gender: Male Diagnosis: Pneumonia Date: 09/08/20 Assessment Pathophysiology Goals Nursing Diagnosis Nursing Interventions

Chief Complaint: Pneumonia with complaints of chest tightness, difficutly breathing and a productive cough for over a week

Pneumonia with chest tightness, difficulty breathing and productive cough Doctor ordered vital signs to be taken every 4 hours Oxygen to maintain SpO2 greater then 92%

Subjective: Patient states that he has chest tightness

IV infusion of normal saline at 75mL/hour Ceftriaxone 1g IVPM every 12 hours

Objective: Initial assessment Vital signs: Alert and oriented x3 Temp (oral): 103F (39.2 C)

Acetaminophen 1000 mg po every 6-hour PRN temperature greater than 101F

AFTER anaphylactic shock the doctor ordered

The patient will maintain an effective breathing pattern, as evidenced by normal rate, depth, oxygen saturation by 1400

Ineffective breathing pattern related to laryngeal edema and bronchospasm as evidenced by coughing, dyspnea, and tachypnea

The patient will demonstrate improved and adequate oxygenation of tissues by ABG’s within normal parameters and absence of symptoms of respiratory distress by 09/09/20

Impaired gas exchange related to alveolar hypoventilation as evidenced by tachypnea and use of accessory muscles

Patients’ airway improved and cleared up after the epinephrine was administered for allergic reaction

Ineffective air way clearance due to patients’ complaints of throat swelling and bronchial spasms heard when auscultating

Rationale

Evaluation

Administer oxygen and monitor patient’s oxygen level

The patient’s oxygen levels dipped down to 88% after allergic reaction and the doctors order said maintain SpO2 greater than 92%

Administer the medication the doctor ordered

The doctor ordered 3 medications for his pneumonia

Short- term goal: to get the patients anaphylactic reaction under control Evaluation: patient was given epinephrine and albuterol and the patients airway

Administer epinephrine that doctor ordered

Patient had an anaphylaxis reaction after Ceftriaxone was given

Administer all NEW medication doctor ordered after reaction

Put 3 lead ECG on Patient was patient to monitor having respiratory heart issues

Assessing patients’ vital signs every 4 hours (BP, respiratory rate,

Look for improvement in vital signs indicating his pneumonia could

Short- term goal: Have the patients Oxygen levels return back within normal limits Evaluation: Patient was given oxygen via a on rebreather mask to help oxygen go up, and is being closely monitored with a pulse oximeter Long- term goal: educate the patient on why the allergic reaction happened and how to prevent it in the future

SpO2: 95% Respiratory rate: 19 breaths per minute

Blood Pressure: 138/82 mm Hg The patient’s lungs were auscultatedreduced breath sounds at the right lung base

0.5 mg of epinephrine 1:1000 was administered intramuscularly

5 mg dose of albuterol was placed in a nebulizer 50 mg dose of diphenhydramine was injected slowly

Heart rate: 97 (normal heart sounds)

125 mg of methylprednisolon e was injected slowly

Assessment of Vital signs after anaphylactic reaction: Conscious state: appropriate

Infusion of ranitidine was started

Temperature: 102 F (39.1C) Respiratory rate: 37 Blood pressure: 137/73 mm Hg SpO2: 88% Heart rate: 148

3 lead ECG to be attached

The patient will display hemodynamic stability (BP, cardiac output, peripheral pulses within normal range) by 1900, 09/08/20

Decreased cardiac output related to alteration in heart rate and rhythm, decreased oxygen, as evidenced by tachypnea, dyspnea and decreased oxygen saturation

pulse, temperature, SpO2 %)

be improving. Also monitor vital signs to see if there is any decline in his health

Evaluation: the patient understood his allergy to Ceftriaxone and that it would be put in his medical record Long- term goal: Provide patient teaching about smoking as much as he does (2 packs a day) and how external factors can cause pneumonia Evaluation: Information to be given upon discharge

ECG: sinus tachycardia

HPI He smokes 2 packs of cigarettes a day Allergic to Ceftriaxone

EP 1/2019; Nursing Care Plan single sheet...