Medical Dx: Pneumonia Patient Hx: Diabetes, HTN.

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Medical Dx: Pneumonia Patient Hx: Diabetes, HTN. by Mind Map: Medical Dx: Pneumonia     Patient Hx: Diabetes, HTN.

1. Nursing Diagnosis #1 Ineffective Airway Clearance

2. Nursing Diagnosis #2 Impaired Gas Exchange

2.1. SMART GOAL: The patient will maintain clear lung fields and remains free of signs of respiratory distress by discharge.

2.2. INTERVENTIONS: 1) Position the patient's HOB elevated at 45 degrees as tolerated. Rationale- Upright position allows increased thoracic capacity and lung expansion. 2) Encourage and assist with ambulation per physicians orders. Rationale- Ambulation facilitates lung expansion, secretion, and stimulates deep breathing. 3) Encourage slow deep breathing and use incentive spirometer as indicated. Rationale- These techniques promote deep inspiration which increases oxygenation. 4) Pace activities and schedule rest periods to prevent fatigue. Rationale- Activities will increase oxygen consumption and should be planned so that the patient doesn't become hypoxic. 5) Instruct patient to limit exposure to persons with respiratory infections. Rationale- This is to reduce the potential spread of droplets between patients.

2.3. Evaluation: The patient maintained clear lung sounds and remained free of respiratory distress by discharge.

3. Lab Values: WBC- 11, platelets- 350,000, RBC- 4.9, BUN- 18, Creatinine- 1.5

4. Nursing Diagnosis #1 Ineffective Airway Clearance

4.1. The patient will maintain oxygen saturation above 92% and will demonstrate effective clearing of secretions.

4.2. INTERVENTIONS: 1) Teach patient how to turn cough and deep breathe Rationale- The best way to clear secretions is coughing. 2) Position the patient upright Rationale- Allows for optimal lung expansion. 3) maintain humidified oxygen as prescribed Rationale- humidified air will decrease thickness of secretions. 4) Encourage patient to increase fluids rationale- Fluids minimize mucosal drying and maximize ciliary action to move secretions. 5) Provide oral care every 4 hrs rationale- Oral care refreshes the mouth after respiratory secretions have been expelled

4.3. Evaluation: The patient maintained her oxygen saturation above 92% and has effectively cleared secretions to maintain patent airway.

5. IMAGING- Chest X-RAY + for inflammation

6. Risk factors and relevant client information- 68 year old male, history of HTN and diabetes. These co-morbidities put the patient at risk for health complications such as pneumonia.

7. Nursing Diagnosis #3 Activity Intolerance

7.1. SMART GOAL: The patient will exhibit tolerance of activity as evidence by normal fluctuation of vital signs during the activity before discharge.

7.2. Interventions: 1) Establish guidelines and goals of activities with the patient. Rationale- motivation and cooperation are enhanced if the patient participates in goals. 2) Evaluate the need for home assistance after discharge. Rationale- collaborate and coordinate meaningful assistance to conserve energy. 3) Assist with ADL's while avoiding dependency. Rationale- facilitate progressive endurance and self esteem. 4) Provide bedside commode as indicated. Rationale- requires less energy expenditure rather than ambulating to bathroom. 5) Encourage physical activity consistent with the patients energy levels. Rationale- Helps promote a sense of autonomy while being realistic about capabilities.

7.3. Evaluation: The patient tolerated walking the down the hall and back to his room without discrepancies in vital signs.

8. Nursing Diagnosis #4 Knowledge Deficit

8.1. SMART GOAL: The patient will explain disease state recognize medications, and understand treatments by discharge.

8.2. INTERVENTIONS: 1) Render physical comfort for the patient. Rationale- Based on Maslow's theory, basic needs must be addressed before anything else. 2) Provide atmosphere of respect, openness, trust, and collaboration. Rationale- Conveying respect is important when providing education to patients with different values and beliefs about health and illness. 3) Consider what is important to the patient. Rationale- Allow the patient to identify the most significant content to be presented in way that is most effective. 4) Support self-directed, self- designed learning. Rationale- This technique aids the learner to form own learning plan and encouraging priority needs. 5) Help patient integrate information into daily life. Rationale- This technique aids the learner to make adjustments in daily life and will result in change in behavior.

8.3. Evaluation: The patient stated importance of understanding the medication regimen and understands treatment and the importance of compliance.


10. Assessment Findings- EXPECTED- SOB, mild chest pain, productive cough, fatigue, activity intolerance, decreased breathe sounds. ACTUAL- SOB, chest pain, productive cough, fatigue, decreased breathe sounds.