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Assessment
General appearance: Mr. Jason appeared uncomfortable and was breathing shallowly and with difficulty Vitals: Blood pressure: 130/80 mmHg/HR 98 beats/minute/O2 88%/Temp 37.9 C/Resp: 20
Neuro: Alert and oriented x3/No signs of confusion or disorientation
HEENT: Conjunctiva and sclera that are normal/There were no lesions or exudates found in the oropharynx/ There was no lymphadenopathy in the cervical or occipital regions
Cardiac: Regular rhythm/No (S3-S4), murmurs, gallops, or rubs
Respiratory: When auscultation was done, the patients lungs were found to have crackles and wheezing sound/Fewer breaths being taken in the right lung/Intense discomfort in the chest upon palpation/Mundane rumblings emanating from the right lung in response to percussion
GI: Absence of stomach discomfort and distention/The presence of bowel sounds/Hepatosplenomegaly was not present
GU/Elimination: There is no urine incontinence at all/Clear urine outflow/On palpation, there are neither lumps nor soreness
Integumentary: Temp 37.9 /No edema or cyanosis/Not a single sore or rash/Good skin turgor
Musculoskeletal: No joint discomfort or stiffness/There is no muscle wasting or atrophy/The standard scope of motion
Psychosocial: No signs of depression or anxiety/No signs of stress
Labs/Diagnostics: Number of white blood cells in the blood: 12,000/mm3/Right lung consolidation and infiltration was seen on the chest x-ray/Streptococcus pneumoniae was found to be growing in the blood culture/Streptococcus pneumoniae was detected in a sputum culture.
Pathophysiology
Pneumonia is a disease brought on by an infection brought on by bacteria or viruses. This infection causes inflammation and lung infection, which can bring symptoms such as trouble breathing, chest discomfort, and fever (NANDA International, 2021). During the examination, Mr. J.A. gave off the impression of being uncomfortable; his breathing was labored and shallow, and he appeared to have difficulty doing so. Upon auscultation, the results of the inspection indicated crackling and wheezing sounds. A decrease in the sounds of breath coming from the right lung was detected during the examination, as was chest pain. A dullness was found on the right lung after percussion was performed. Concerning aspects of the assessment included a lessening of breath sounds, crackles on auscultation, chest discomfort, and dullness when percussion was performed.
Pneumonia requires the entry of a pathogen into the alveoli and the subsequent defeat of the hosts defenses, either due to the virulence of the microorganism or the magnitude of the inoculum. Sinusitis, oropharynx colonization, stomach, trachea, and hematogenous spread are all endogenous transmissions. The intestinal tract is yet another endogenous supply. Bacterial pneumonia, viral pneumonia, and mycoplasma pneumonia are the three main types of pneumonia. A cough that produces yellow, green, or red mucus is the most common symptom of pneumonia. Four distinct phases characterize the progression of pneumonia: congestion, red hepatization, gray hepatization, and resolution (Center for Disease Control, 2022). A persons symptoms tend to worsen during the first three stages of disease until finally improving during the fourth phase when the immune cells successfully eradicate the infection.
The provision of psychological, social, and spiritual care in a manner sensitive to local customs through therapeutic dialogue is what is known as psychosocial care.
This category includes hopelessness and powerlessness, situational low self-esteem, risk for situational low self-esteem, readiness for enhanced self-concept, and disturbed body image. The available research demonstrates that providing patients with adequate psychosocial treatment can enhance their health outcomes and quality of life.
Since it is painful to move the chest wall and fluid in the lungs due to a compensatory response to airway obstruction, tachypnea, short respirations, and asymmetric chest movement are usually observed in patients with this condition. Alterations in breathing patterns may take place in conjunction with the use of accessory muscles to increase chest excursion in order to make breathing easier.
Linkages and Rationale of Diagnosis
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The underlying pathophysiology of pneumonia is the connecting thread that intertwines and interconnects the nursing diagnosis.
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The patient is suffering from severe discomfort as a direct consequence of the infection and inflammation that is taking place in their lungs.
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The severe pain and the disruption in gas exchange are the underlying causes of the inefficient breathing pattern.
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The infection and inflammation in the lungs, which leads to difficulties breathing, are directly responsible for the poor gas exchange that occurs as a result.
Rationale for Selected Goals
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Nursing diagnoses for this patient were chosen with the evaluation results and the patients underlying pathophysiology of pneumonia in mind.
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The nursing diagnosis was identified as acute pain, an inefficient breathing pattern, and poor gas exchange.
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When the patients chest was palpated, he felt pain, which may be traced to the inflammation and infection in his lungs.
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Nursing professionals concluded that the patient was experiencing acute pain and made that diagnosis.
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The clients shallow, labored breathing contributed to the nurses diagnosis of an inefficient breathing pattern due to the patients extreme discomfort and the resulting reduction in gas exchange.
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Following auscultation, the clients breath sounds and crackles had diminished, likely due to the infection and lung inflammation.
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Based on these observations, the nursing staff diagnosed the patient with limited gas exchange. The nursing diagnosis is intertwined and connected by the underlying pathophysiology of pneumonia.
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Because of the infection and inflammation in the customers lungs, they are in excruciating pain.
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The ineffective breathing pattern is due to intense pain and the disturbance in gas exchange.
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If one is having trouble breathing, it is likely because of an infection or inflammation in the lungs, which can hinder gas exchange.
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Since these are the patients most pressing issues and concerns, we believe these nursing diagnoses are the best overall fit.
Infection Control, Safety, and Communication
A chest X-ray is frequently utilized in the diagnostic process for pneumonia. Blood tests, such as a complete blood count (CBC), can determine whether or not the immune system is battling an illness. Pulse oximetry is a method for determining the amount of oxygen in the blood. In order to prevent patients from becoming dehydrated, nurses should encourage them to consume more water and, if necessary, use oral rehydration solutions (ORS) or intravenous therapy to maintain appropriate electrolyte levels. They should perform pulse oximetry on them at least once every two to four hours to monitor their oxygen levels.
References
Center for Disease Control. (2022). Pneumonia. Centers for Disease Control and Prevention. Web.
NANDA International. (2021). Nanda-I Definitions & Classification, 2021-2023 now available (English): Nanda International, Inc. NANDA International, Inc |. Web.
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