Patient Introduction Location: Medical Unit Time: 11:00 Situ

Patient Introduction Location: Medical Unit Time: 11:00 Situation:…  Patient IntroductionLocation: Medical UnitTime: 11:00Situation:The patient is Kenneth Bronson, a 27-year-old male who just arrived at the Medical Unit from the Emergency Department with the diagnosis of right lower lobe pneumonia confirmed by chest x-ray.Background:He presented to the Emergency Department 2 hours ago with chest tightness and difficulty breathing in addition to the productive cough, fever, and fatigue he’s had for about a week. He has a history of smoking for 10 years.Assessment:He was given acetaminophen 650 mg orally in the Emergency Department for a temperature of 102.6 °F (39.2 °C). Heart rate has been in the 80s, respiratory rate is 24, and blood pressure is 132/80 at the right arm. SpO2 on room air was 90%, which increased to 93% with supplemental oxygen 2 L per nasal cannula. He has a 20-gauge IV in the left hand with normal saline infusing at 75 mL/hr.Recommendation:Provider’s orders and lab results are available in the chart for you to view. Pharmacy just delivered the IV antibiotic that needs to be given and will bring the oral antibiotic within the next hour. NURSING DIAGNOSES/ GOALS/ INTERVENTIONS: Medical Diagnosis:  PneumoniaPathophysiology: An infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus causing cough, phlegm, pus, fever, and chills  Nursing Process – Nursing Diagnosis:1. Ineffective airway clearance related to inflammation of the lung parynchema as evidenced by productive cough and dyspnea.2. Ineffective breathing pattern related to laryngeal edema and bronchospasm as evidenced by coughing, dyspnea, and tachypnea3. Impaired gas exchange related to alveolar hypoventilation as evidenced by tachypnea and use of accessory muscles  S: Fill out the supporting data, the table,  and the evaluation.  The diagnosis is given. (Nursing Diagnosis #1) highest priority: Ineffective airway clearance related to inflammation of the lung parynchema as evidenced by productive cough and dyspnea. Supporting data:  Provide data from your assessment (Subjective/ objective) and any relevant labs or diagnostic images that specifically support your nursing diagnosis.  Goal (S.M.A.R.T.):S.M.A.R.T= Specific, Measurable, Attainable, Realistic, Timed Nursing Interventions to achieve goal:MUST BE EVIDENCE BASED- cite your sources 1. 2. 3. 4. Nursing process: Evaluation #1: Describe how your patient met/did not meet goal- what would you want the outcome to be? Hypothetically? What could be improved?   (Nursing Diagnosis #2): Second priority: Ineffective breathing pattern related to laryngeal edema and bronchospasm as evidenced by coughing, dyspnea, and tachypnea Supporting data: Provide data from your assessment (Subjective/ objective) and any relevant labs or diagnostic images that specifically support your nursing diagnosis Goal (S.M.A.R.T.): S.M.A.R.T= Specific, Measurable, Attainable, Realistic, Timed Nursing Intervention to achieve goal:MUST BE EVIDENCE BASED- cite your sources1. 2.3. 4. Nursing process: Evaluation #2: Describe how your patient met/did not meet goal- what would you want the outcome to be? Hypothetically? What could be improved?   (Nursing Diagnosis #3): lowest priority: Impaired gas exchange related to alveolar hypoventilation as evidenced by tachypnea and use of accessory muscles  Supporting data: Provide data from your assessment (Subjective/ objective) and any relevant labs or diagnostic images that specifically support your nursing diagnosis Goal (S.M.A.R.T.): S.M.A.R.T= Specific, Measurable, Attainable, Realistic, Timed Nursing Intervention to achieve goal:MUST BE EVIDENCE BASED- cite your sources1. 2. 3. 4.  Nursing process: Evaluation #3: Describe how your patient met/did not meet goal- what would you want the outcome to be? Hypothetically? What could be improved?   Citations are expected.  Provide citations for any resourced data.  References:Health Science Science Nursing NURS 202

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