Nursing Care Plan A Client with Pneumonia

1 1088 UNIT X / Responses to Altered Respiratory FunctionMary O Neal is a 35-year-old executive assis-tant and a part-time college student. On return-ing home from class one evening, she begins to chill. She alter-nates between chills and sweats all night. Staying home fromwork, she remains in bed most of the next day. Her fever continues,and she develops a cough and dull aching chest pain. When thecough becomes productive of rust-colored sputum the followingday, she seeks medical treatment from her family Kowalski, RN, the family practice clinic nurse, admits Neal to the clinic and obtains the Nursing assessment. Neal denies any previous history of respiratory diseases otherthan the usual colds, flu, and such. She also denies any history ofsmoking or medication allergies. She says her symptoms beganabruptly with the onset of the chills. She describes her chest painas a dull ache that was initially substernal but now is localized inher lower lateral right chest.

2 The pain increases with deep breath-ing, coughing, and moving. Her cough is increasing in frequencyand severity, and her sputum appears rusty brown. Her vital signsare BP 116/74, P 104 and regular, R 26,T F ( C). Skin warmand flushed, with no evidence of cyanosis. Respirations shallow,unlabored; respiratory excursion equal. Diminished breath soundsin bases bilaterally, crackles noted in right posterior and lateralbase. Faint pleural rub heard at right midaxillary STAT CBC shows a WBC of 18,900/mm3;differential showsincreased numbers of neutophils and immature WBCs (bands).Ms. Kowalski has Mrs. O Neal rinse with an antiseptic mouthwashand collect a sputum specimen for culture and Gram stain prior toseeing the physician orders a chest X-ray after examining Mrs. O on her history, examination, and the chest X-ray, he makesthe diagnosis of acute bacterial Pneumonia , probably pneumo-coccal.

3 He prescribes oral penicillin V, 500 mg every 6 hours for10 days. He asks Mrs. O Neal to return for a follow-up appointmentin 10 days and refers her back to Ms. Kowalski for Kowalski develops the following Nursing diagnoses for Neal. Ineffective breathing patternrelated to pleuritic chest pain Hyperthermiarelated to inflammatory process Deficient knowledgeabout Pneumonia and its treatmentEXPECTED OUTCOMESThe expected outcomes for the plan of care specify that Neal will: Maintain normal pulmonary function. Describe measures to minimize elevations in body tempera-ture. Identify a schedule for taking her medication that will facilitatecompliance with the regimen. Describe manifestations that should be reported to the AND IMPLEMENTATIONMs. Kowalski plans and implements the following interventionsfor Neal. Assess knowledge and understanding of Pneumonia and itseffects.

4 Assist to develop a medication schedule that coordinates withnormal daily routine. Teach about the following:a. Importance of avoiding use of a cough suppressant exceptat night to facilitate restb. Ways to increase fluid intake to reduce fever and maintainthin mucus for easy expectorationc. Beneficial effects of rest, especially during the acute phaseof her use of aspirin and acetaminophen to reduce fevere. Importance of taking all prescribed medication doses side effects of penicillin V and their manifestations of penicillin allergy that necessitatestopping the medication and notifying the physicianh. Signs of complications of Pneumonia or worsening pneu-monia to reportEVALUATIONThe sputum culture confirms S. pneumoniaeas the cause of Neal s Pneumonia . When she returns for her follow-up ap-pointment, she reports that she began to feel better after 2 dayson the penicillin and returned to work the following Monday.

5 Herexamination reveals good breath sounds throughout with noadventitious sounds. The follow-up sputum culture is free Thinking in the Nursing Process1. Do any of the factors identified in the case study increase Neal s risk for acute bacterial Pneumonia ?2. Mrs. O Neal s WBC differential showed increased neutrophiland band counts. Describe the reason for and effect of Even though Mrs. O Neal has no history of medication aller-gies, anaphylactic shock remains a potential risk. Describe thesequence of events leading to anaphylactic shock, its initialsymptoms, and immediate Nursing Had Mrs. O Neal required hospitalization to treat her acutepneumonia, interruption of her usual activities and responsi-bilities could lead to anxiety. Develop a care plan for this situ-ation, using the Nursing diagnosis,Altered role performancerelated to Critical Thinking in the Nursing Process in Appendix care PlanA Client with Pneumonia