Nursing Concept Map-Bacterial Pneumonia map PDF

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Summary

Bacteria Pneumonia for Foundational of Nursing NUR 215....

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Pathophysiology (In your own words-cite reference) According to NCBI, bacterial pneumonia is an inflammation of the bronchioles and alveoli due to the Infection. The bacterial pneumonia saturate the macrophages and produce fibrin-rich exudate that fills infected nearby alveolar spaces.

Causative org: streptococcus pneumoniae Clin Mani: fever, pleuritic chest pain, tachypnea, fatigue, confusion, cough Sattar SBA, Sharma S. Bacterial Pneumonia. [Updated 2021 May 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 https://www.ncbi.nlm.nih.gov/books/NBK 513321/

Bacterial Pneumonia

Assessment Data- min. of 3

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

Subjective: 1. headaches

Ineffective thermoregulation related to the infectious process of bacterial pneumonia as evidenced by temperature of 102 F, shortness of breath, and tachypnea.

2.shortness of breath 3. fatigue Objective: 1. fever: 102 F 2. O2 saturation level: 89% 3. tachypnea

1. Patient will have a stabilized temperature within the normal range in 12 hours.

Planning- Short Term Goal #2

Ineffective airway clearance related to the disease process of bacterial pneumonia as evidenced by shortness of breath and decreased air entry lung left lower lobe.

1. Patient will demonstrate techniques to improved airway clearance such as expectorate phlegm and cough effectively within 12 hours.

2. Patient will demonstrate behaviors improving airway clearance and expectorate phlegm. Rationale: To help clear thick phlegm that patient is unable to expectorate and maximize the ventilation.

1.Remove excessive clothing, blankets and linens. Adjust the room temperature. Rationale: To regulate temperature of the environment and make it more comfortable for the patient. 2. Assess the patient’s vital signs

Planning- Short Term Goal #1

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

Nursing Interventions for Goal #2- min. of 2 1. Elevate the head of the bed and assist the patient to assume semiFowler’s position. Rationale: Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breath more effectively.

Nursing Interventions for Goal #1- min. of 2

at every 4 hours. Rationale: To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drug (Tylenol) administered. Osilla EV, Marsidi JL, Sharma S. Physiology, Temperature Regulation. [Updated 2021 May 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Janhttps://www.ncbi.nlm.nih.gov/books/NB K507838/

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 not met. Patient fever did not decline below 102F.

Next step: Patient will demonstrate breathing techniques within 24 hours. STG #2- Goal met. Patient demonstrate effective airway clearance within 24 hours....