Clinical Reasoning for a Patient with Pneumonia
Focused Assessment Data:
The case study provides a huge amount of assessment data on Mr. G. For reasons of physiological urgency the nurse has decided to focus on one Basic Human Need (oxygenation). And within a range of oxygenation problems, the nurse is considering the infective process (pneumonia) that is causing considerable difficulty. Thus, only the assessments that suggest pneumonia are listed here. It is not that the remaining assessment data is not important. It is!. But it doesn't inform us about this one priority problem.
The vital signs support the problem statement because they demonstrate fever, tachycardia and tachypnea which makes sense in a patient who is hypoxic. Both fever and hypoxia will activate the sympathetic nervous system driving heart and respiratory rate.
The immediate (siezures) and past history (alcoholism) provide a reasonable probability that the patient was susceptible to depression of protective reflexes (gag, swallowing, cough) and consequent aspiration of stomach contents.
Chest auscultation: Taken together with the findings on CXR, these abnormal breath (and adventitious) sounds support the presence of heavy, airless regions of the lung under the head of the nurse's stethoscope. In pneumonia, alveoli collapse as well as fill with the by-products of an inflammatory process while at the same time, the intercelluar spaces of the lung can become edematous.
Cough: As might be expected inflammation activates sensory afferent neurons, producing an almost irresistible urge to cough. The "wet" sounds are those of exudate and mucous that has seeped into the larger airways. The fact that the patient is not able to raise the secretions may be a consequence of his weakness and dehydration.
The vital signs support the problem statement because they demonstrate fever, tachycardia and tachypnea which makes sense in a patient who is hypoxic. Both fever and hypoxia will activate the sympathetic nervous system driving heart and respiratory rate.
The immediate (siezures) and past history (alcoholism) provide a reasonable probability that the patient was susceptible to depression of protective reflexes (gag, swallowing, cough) and consequent aspiration of stomach contents.
Chest auscultation: Taken together with the findings on CXR, these abnormal breath (and adventitious) sounds support the presence of heavy, airless regions of the lung under the head of the nurse's stethoscope. In pneumonia, alveoli collapse as well as fill with the by-products of an inflammatory process while at the same time, the intercelluar spaces of the lung can become edematous.
Cough: As might be expected inflammation activates sensory afferent neurons, producing an almost irresistible urge to cough. The "wet" sounds are those of exudate and mucous that has seeped into the larger airways. The fact that the patient is not able to raise the secretions may be a consequence of his weakness and dehydration.
Problem Statement:
As discussed previously, these problem statements serve a purpose similar to diagnoses established by NANDA-I. They are also written in 3-part NANDA-I syntax. (Problem RT Cause AEB summary of or most compelling assessment data.) Once there is a clear understanding of the principles underlying the patient's problem, a suitable NANDA-I diagnosis can be appropriately applied. Mr. G's priority problem is that he is very hypoxic even with supplemental O2. The most obvious and immediate (as well as treatable) cause is the lung infection (most probably aspiration related) and there is abundant assessment data that can support the problem as identified.
Goals:
The 4 goals that are listed are specifically related to the patient's pneumonia-related hypoxemia. Since most of the treatment for pneumonia is by means of antibiotics, the goals and nursing actions are largely collaborative. Nevertheless... they fit the requirements for proper goal statements: 1) the goals clearly relate to this particular diagnosis (2) are patient related (not a nursing action disguised as a goal), 3) in a time context and 4) measurable or binary (yes/no).
Nursing Actions:
The actions begin with hydration since there is laboratory data indicating he is dehydrated, which will tend to make his secretions thicker and drier. The nebulization also will get water to the mucous plugged airways (and if it also contains a beta-2 agonist like abuterol, it will help relax the airway smooth muscle.)
NOTE: The next nursing action is very important. If the patient has an infection that will be treated with antibiotics, you must send culture specimens to the lab before the first dose is administered. Even a brief exposure to IV antibiotics will radically alter the viable pathogens in the sputum, and the antibiotic most specific for the infective organism may never be determined.
There should be as little delay as possible before the first dose of antibiotics, and the nurse has already observed that the patient is not raising sputum on his own. This is one occasion when deep naso-tracheal suctioning is indicated.
Next the IV antibiotics are begun. The patient is supported on a high concentration of inhaled oxygen, and frequent close monitoring is put into effect.
NOTE: The next nursing action is very important. If the patient has an infection that will be treated with antibiotics, you must send culture specimens to the lab before the first dose is administered. Even a brief exposure to IV antibiotics will radically alter the viable pathogens in the sputum, and the antibiotic most specific for the infective organism may never be determined.
There should be as little delay as possible before the first dose of antibiotics, and the nurse has already observed that the patient is not raising sputum on his own. This is one occasion when deep naso-tracheal suctioning is indicated.
Next the IV antibiotics are begun. The patient is supported on a high concentration of inhaled oxygen, and frequent close monitoring is put into effect.