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Transcript of Pneumonia
Admitting Diagnosis: Pneumonia
Chief Complaint: Shortness of Breath
Signs and symptoms
Treatments patient received
Head to Toe
Nursing Care and Treatments
1. Impaired gas exchange related to pneumonia as evidenced by shortness of breath, cough and oxygen dependent on six liters.
Pt will be weaned to four liters of oxygen (to go home rate/baseline) and maintain a 92% or above oxygen saturation before end of shift today at 1830.
2. Diarrhea related to radiation as evidenced by three loose stools before 1100 and hyperactive bowel sounds in all four quadrants.
Pt will decrease in number of bowel movements and have formed stools by end of shift today at 1830.
3. Risk for bleeding related to adenocarcinoma on the left lung as evidenced by elevated coagulation and bruising bilaterally upper extremities.
Pt will be able to discuss precautions to prevent bleeding complications today before end of shift at 1830.
Question and Answer
Ackley, B. J., &Ladwig, G.B. (2014). Nursing diagnosis handbook (10th
ed.). St. Louis, MO:Elsevier Mosby.
Amalia, A., & Torres, A. (2013). Pathophysiology of Pneumonia. Clinics in
Chest Medicine, 26, 39-46. doi: 10.1010/j.com.2013.10.004
Ignatavicius, D.D. & Workman, M. L. (2015). Medical-surgical nursing:
Patient-centered collaborative care. (8th ed). St. Louis: Saunders/
J. George (2014, May 10). Pneumonia vs. Pneumonitis [Video file].
Retrieved from http://khanacademy.org/science/health-and-medicine/