Case Study: การตรวจสอบย้อนกลับในเนื้อสัตว์ · 38 Case Study: การตรวจสอบย้อนกลับในเนื้อสัตว์
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Kingdome of Saudi Arabia
Ministry of higher education
University of hail
Critical nursing
Case study: Pneumonia
Talal Qassem Shapi
patient's Name(initials): A. H. M
Unit:: micu
Medical diagnosis: old CVA And pneumonia
DEMOGRAPHIC DATAName : Ayed Hamad Motlaq Al Shammary.
Age: 80 yr.
Educational level:: NON
Occupation: NON
Admission date: At 16.30 22\6\35
Sex:: Male
Nationality:: Saudi
HEALTH HISTORYHISTORY OF PRESENT ILLNESS:
The Patient Has Short Of Breath With Low Level Of
Conciseness With Hypertension According To The Pt.
Family He Was Bedridden Since 10 Yr. Ago Because Of
CVA And Yesterday He Has Cough And Short Of Breath
And Hypertension .
PAST MEDICAL HISTORY:
HTN. Bedsores. OLD CVA. Hemiplegia .
FAMILY MEDICAL HISTORY:
He Had History Of Hypertension And Bed Redden since
10yr ago.
DISEASE PROCESSDEFINITION
Pneumonia: is an inflammatory process involving the terminal airways and alveoli of the lungs caused by infectious agents.
SING AND SYMPTOMS
Cause:
Pneumonia is due to infections caused primarily by bacteria or viruses and less commonly by fungi and parasites.
Etiologic Agents
S.aureus
Enterobacteriaceae
P.aeruginosa
Acinetobacter sp.
Polymicrobial
Anaerobic bacteria
Legionella sp.
Aspergillus sp.
Viral
PHYSICAL ASSESSMENT
Inspection
SOB
diaphoresis
chills
respiratory distress
palpation
decreased chest expansion or asymmetry
lymphadenopathy
PHYSICAL ASSESSMENT
percussion
dull
decreased diaphragmatic excursion
auscultation
bronchial breath sounds in periphery
decreased air entry
wheezes and crackles
DIAGNOSTIC TESTS ,PROCEDURES Chest x-ray shows presence\ extent of pulmonary disease
typically consolidation.
Gram stain and culture and sensitivity test of sputum my indicate offending organism.
Blood culture detects bacteremia (bloodstream
invasion)occurring with bacterial pneumonia.
Immunologic test detects microbial antigens in serum, sputum and urine.
DIAGNOSTIC TESTS ,PROCEDURES
ResultInvestigationvery prominent wedge-shape area of
airspace consolidation in the right lung CXR
Sinus Tachycardia ECG
20.09WBC
9.2HGB
413PLT
213CREAT
32BUN
Chest x-ray A chest X-ray showing
a very prominent wedge-shape area of airspace consolidation in the right lung characteristic of bacterial pneumonia.
Vital Signs:
SPO2B.PR.RTempH.RTime
96%119/823836.993Admission
94%105/673637.91039AM
96%109/704038.310710AM
97%123/81413810711AM
95%111/773937.98612MD
97%110/803037.91071PM
medicationNursing
interventiondoseindicationclassificationmedication
Give slowly with diluted by NS
1.2mgTIDi.v
infectionAntibioticAmoxicillin and
clavulanatepotassium
Augmentin
Give slowly with diluted by NS
500mgODi.v
Bacterial infection
Antibioticsfluoroquinolones
levofloxacin
Observe human albumin in
blood
100mlODi.v
To replace blood volume
loss
Human protein Human albumin
Observe any sing of bleeding
4mlODsc
immobilityAnticoagulant Sodium
enoxaparin
Clexane
Give slowly 1gQIDi.v
Painfever
Pain relieveracetaminophen
paracetamol
Nursing process
Assessment With unproductive cough
With wheezes and crackles auscultated on left lower lung field.
Presence of clear watery discharge from her nose.
Short of breath.
Nursing Diagnosis Ineffective airway clearance related to presence of
secretions secondary to pneumonia.
goal
Short Term
After 3-4 hours of nursing interventions, the patient’s respiration will improve and difficulty of breathing will be relieved.
Long Term
After 3 – 4 days of nursing interventions, the patient will maintain a patent airway.
NURSING INTERVENTIONS
Monitor and record V/S.
Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds.
Assist patient to change position every 30 minute
Provide health teachings regarding effective coughing and deep breathing exercise.
Encourage to increase fluid intake.
Administer meds as ordered.
Evaluation
Short Term:
After 3-4 Hours Of Nursing Interventions, The Patient’s Respiration Have Improved goal is met.
Long Term:
After 3 – 4 Days Of Nursing Interventions, The Patient Have Been Able To Maintain A Patent Airway goal is met.
Assessment
Flushed Skin.
Skin Warm To Touch.
Temperature Higher Than 37.6c
Dehydration.
Nursing Diagnosis
Risk For Infection R\t Inadequate Primary Defenses.
goal
Short term
After 4°h of nursing intervention the pt.'s temperature will drop from 38.4 °C to 37 °C
Long term:
After 2-3 days of nursing intervention the patient will be free from hyperthermia.
NURSING INTERVENTIONS
Give antipyretic as order.
Assess skin temperature and color.
Monitor WBC count.
Encourage fluid intake orally or intravenously as ordered.
Measure intake and output.
Evaluation
Short term:
After 4h° of nursing intervention the pt.'s temperature drop from 38.4 °C to 37.4 °C or lower. goal is met
Long term:
After 2-3 days of Nursing intervention , the patient free from hyperthermia. Goal is met.
PATIENT EDUCATION Eating Well Balanced Meals
Adequate Rest
Avoiding Upper Respiratory Infections Or Getting Promptly Treatment For Early Symptoms
Drinking Large Amounts Of Fluids To Thin Secretions And Replace Fluid Loss
Avoiding Spread Of Infections By Washing Hands And Properly Dispose Of Tissues
Avoid Smoking; Perform Coughing And Deep Breathing exercises.