Bacterial Pneumonia

Initial assessment

Ht. 5’8”, Wt. 210 lbs

BP 144/89

Alert

T 99.8 #

R 18

P 88

Skin

Pink, warm, dry

Surgical incision #

Right hip approximated with staples, no drainage, surrounding skin is without erythema.

Respiratory #

Cardiac

Even and unlabored

Productive cough

Crackles in right posterior base

O2 saturation 90% on 2 L NC

Heart rhythm is regular

S1 S2 without murmur

Pedal pulses +1 bilaterally

Capillary refill is <3 seconds in all extremities

Abdomen # #

Bowel sounds present X 4

Soft and non-tender to palpation

Passing flatus

Last BM was this morning

Mental status

Orientated X 3

Mobility

Needs assistance with repositioning in bed

Needs lots of encouragement to ambulate

Ambulates with assist of 1 and a walker with lots of cueing

Tolerates activity fair

Tires easily #

Lab Values

Basic Metabolic Panel:

CXR

CBC

Hgb: 13.2 (L)

Hct: 40% (N)

WBC: 14,300 (14.3) (H)

Na: 140 (N)

K: 3.7 (N)

Ca: 9 (N)

FPG: 145 (H) # #

BUN: 20 (N)

Crt: 1.1 (N)

Consolidation in Right Lower Lobe #

Pathophysiology: Pneumonia is the inflammation of the lung caused by bacteria, virus, or mycoplasma infections. Typical pneumonia is bacterial, and can be classified as lobar pneumonia or Bronchopneumonia. Typical Pneumonia usually has a sudden onset of signs and symptoms such as malaise, high fever, productive cough, and pleuritic pain along with elevated WBC count and consolidation in a chest x-ray (Voss, J.A., n.d.).

                  Work Cited:

Risk Factors

Impaired immune system (chemotherapy drug use, HIV/AIDS, organ transplant patients)

Limited mobility # #

Recent surgery

Clinical Manifestaions

Nursing Diagnosis/Problems

3.) Impaired physical mobility resulting from recent surgery

2.) Ineffective gas exchange as evidence by low O2 sat.

4.) Risk for unstable blood glucose as evidenced by FPG of 145 # # #

Outcomes

Interventions

The patient will TCDB once each hour for 2 weeks (Vera, 2013). #

The patient will monitor blood glucose levels before meals and before bed until doctor states otherwise. (Vera, 2013). #

The patient will continue O2 usage until told otherwise. #

The patient will drink at least 2000 mL of H20 each day for two weeks (Vera, 2013).

Administer IV antibiotics in prescribed doses at prescribed times

Humidifier to break up secretions in lungs (WebMD, 2018).

Health History

PRIORITY NURSING ASSESSMENT

Elevated WBC count

Fever (Mild in elderly)

Productive Cough Present

Low O2 Sat

SOB

Yellow Sputum

Hypothyroidism # # #

Osteoarthritis #

Chronic disease

COPD #

Smoking # # #

Asthma # # #

Heart disease #

Mental status #

Mobility #

Vitals #

Skin (Mobility/Turgor/Hydration status) #

Respiratory Assessment #

1.) Ineffective airway clearance related to inflammation and accumulation of secretions #

WebMD. (2018). What Is Bacterial Pneumonia? Retrieved March 28, 2018, from https://www.webmd.com/lung/bacterial-pneumonia#2-5 : :

Educate patient on the affects smoking has to his lungs

Encourage patient to stop smoking (WebMD, 2018).

Limit visitor use so bacteria does not sperad (WebMD, 2018).

Educate patient on the importance of expectorating lung secretions instead of swallowing

Vera, M. (2013, July 13). 8+ Pneumonia Nursing Care Plans. Retrieved March 28, 2018, from https://nurseslabs.com/8-pneumonia-nursing-care-plans/

Elevate HOB to help expand lungs

Chest physiotherapy/chest percussion (Vera, 2013),

The patient will use incentive spirometer 10-15 times every 1-2 hours while awake, for two weeks. #

Teach patient the importance of monitoring blood glucose levels

Maintain oxygen administration device as ordered

Teach patient importance of ambulation and frequent position changes

Suction as necessary (Vera, 2013).

Assist patient in identifying and modifying unhealthy eating habits

Diagnostics

WBC count (Voss, J.A., n.d.)

Chest x-ray (Voss, J.A., n.d.)

Sputum cultures (Voss, J.A., n.d.) #

Blood cultures (Voss, J.A., n.d.) #

ABGs (Vera, 2013) #

Do a saltwater gargle to help with cough (Vera, 2013).

Contact doctor to receive an order for monitoring blood sugar

Monitor surgical incision for impaired healing related to high FPG

Perform active and passive ROM with patient

Monitor lung expansion as immobility can impair lung expansion

Monitor urinary output to ensure urinary stasis has not occured due to immobility

The patient will get up to the chair for at least 1 hour per day # # #

High FPG #

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Voss, J.A. (n.d.) Respiratory Disorders [PowerPoint slides 31-36].

Hospitalization, especially when on a ventilator

Under 2 years of age or over 65

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