Pneumonia is an infection of one or both lungs, and is typically caused by bacteria, viruses, fungi, or parasites.

It is characterized primarily by inflammation of the alveoli in the lungs or by alveoli that are
filled with fluid. Although the disease can occur in young and healthy people, it is most dangerous for older adults, babies, and people with other diseases or impaired immune systems.
Pneumonia can be acquired by inhaling small droplets that contain the organisms that cause it. These pathogens are transmitted when an infected person coughs or sneezes. In other cases, pneumonia is
acquired when bacteria or viruses inadvertently enter the lung (s); aspiration of bodily fluids and/or foreign materials. Normally, the body's reflex response—coughing—and the immune response will
prevent the aspirated organisms from entering the lungs and causing the infection. However, if a person has a weak or absent gag/cough reflex and/or has a compromised immune system, severe
pneumonia can develop. Pneumonia signs and symptoms typically have a rapid onset and range from mild to severe. Pneumonia is easily diagnosed and treated. Untreated pneumonia may lead to sever
complications including respiratory failure and death.

Admission History
Risk Factors for Pneumonia:
Demographics
Chief Complaint
* People older than age 65
* Weakened or suppressed immune system Pt. Initials: RO Room: 7224 Gender/Race/Age: M, Asian Buddhist 83 Fatigue, weakness, poor appetite
* Chronic illness Ht: 166.4cm Wt: 68kg Admitting Diagnosis
* Weak cough reflex Leukocytosis, pneumonia, abnormal
* Exposure to chemicals, pollutants, and toxic fumes Allergies: NKA Code Status: Full Advanced Directives: None
Labs: WBC 17.8, Hgb 9.4, Hct 29.3, Plt
*Hospital stays
* Placement on a ventilator Precautions: Standard 472
* Crowded living conditions Diet: Nepro via post-pyloric NG tube
* Exposure to airborne droplets Current Diagnoses
* Poor nutrition Activity: Bed rest; patient sedated Pneumonia, Respiratory failure
* Allergies or asthma
* Debilitated state Date of Admission: 08/05/2015
Date of Care: 08/24/2015 Labs
Hematology
Chemistry profile
Clinical Manifestations of Pneumonia: Cultural Considerations: ABG’s
Asian, Buddhist generally do not make eye contact while conversing and often Diagnostics
* Coughing; may be productive or nonproductive look down instead. They prefer a larger area of personal space than western *Chest X-ray-
* Shortness of breath cultures. It is considered disrespectful to position oneself higher than the oldest Persistent pneumonia
* Tachypnea member of the family. It is generally acceptable to greet someone with a *Urine and blood
* Hypoxemia
handshake or by bowing the head. A loud tone of voice means that you are cultures
* Adventitious lung sounds
* Fever showing anger. Buddhist prefer to speak in a very calm and indirect manner. Is *
*Sweating and chills common for Buddhist to not express their feelings or emotions when
* Dehydration communicating.
* Malaise Rice is the main food staple in Vietnamese culture along with vegetables, bread,
* Muscle aches Medical Hx
* Pleuritic chest pain
and noodles. Cold/iced beverages are not acceptable and after childbirth only
*Emphysema
* Pulmonary consolidation; crackles/course lung sounds warm or hot water should to be consumed. Lactose intolerance is common so
*Diabetes-diet controlled
* Retractions good food sources of calcium include tofu, bok- choy, mustard greens, and
*Anemia
* Grunting broccoli. *Tobacco abuse
* Nausea and vomiting Patient was sedated, however all of the above would have been considered and
* Poor appetite *AAA without rupture
accommodated for my patient had I interacted with him. Additionally patient *Hyperlipidemia
* Irritability/agitation
* Headache was a full code and without advanced directives which were noted in his *Postherpetic Neuralgia
* Abnormal labs results: Platelets, WBC, Bands, BUN, chart/EMR. Additionally, patient does not have a large family, and had no *Mild cognitive impairment
creatinine visitors. He only has a niece that lives near his home that visits him occasionally.
Thus patient will require many community and in home resources upon
discharge. (Cherry 2011)

NANDAS – Purple Medications – Red

Outcome/Goals – Pink Labs/Diagnostic Results - Orange
Interventions – Green Clinical Manifestations – Yellow
 Pneumonia

Bacterial infection: Viral Infection: Fungal Infection:

Streptococcus Initial diagnosis by CXR findings;
Influenza Pseudomonas
Streptococcus “patchy ground glass opacities
Adenovirus Candida
Pneumococcus throughout right lung suggestive
Respiratory Syncytial virus
of pneumonia.”
Doxycycline
100mg IVPB Organisms enter and
Q12hrs colonize in the mucous
Solumedrol cells of the nasopharynx
60mg IVP
Q24hrs
Congestion of bronchioles, necrosis and
Host defense mechanisms fail to prevent
WBC 17.8 sloughing of bronchial mucous
organisms from migrating into lower
membranes; formation of peribronchial
respiratory tract; lower respiratory tract
abscesses and pneumatoceles (air filled
infection can begin in one to three days.
cavities)

Lobar Pneumonia Bronchopneumonia Interstitial Pneumonia

(Usually pneumococcal) (Usually Staphylococcal) (Usually viral or streptococcal

Bronchopneumonia
1) Infection → engorgement Doxycycline (Usually
Mucopurulent Inflammation of walls of
with effusion of blood and 100mg IVPB Staphylococcal) alveoli, bronchi and
exudates collect
serum into alveoli in one or Q12hrs bronchioles
in terminal
more lobes Solumedrol bronchioles
(Patient WBC 17.8 on admit) 60mg IVP Inflammation of walls
Q24hrs of alveoli, bronchi and
Atelectasis
2) Alveoli infiltrated with Congestion of bronchioles
and or
red blood cells, fibrin, and bronchioles, necrosis and bronchospas
leukocytes. sloughing of bronchial ms
mucous membranes

3) Consolidation of
leukocytes and fibrin within Small airway
the affected areas occurs. obstructions/congestio
(08/18CXR: Ground glass n, air trapping, and
opacities throughout lungs) increased airway
resistance.

4) Formation of
peribronchial
abscesses and
pneumatoceles (air
filled cavities)
 Respiratory infection Bronchial Acute narrowing and Mucosa become swollen
constriction/contraction of obstruction of the and inflamed, greater
Respiratory infection the smooth muscle of the respiratory airway reduction of already
bronchi narrowed airways
Acute narrowing and
Response by the autonomic Bronchial obstruction of the respirat Mucosa become swollen
nervous system or influence of constriction/contraction of GreaterOrganisms
effort needed
entertoand
move and inflamed,
Bronchial greater
glands produce
anaphylatoxins/complement the smooth muscle of the air in order to meet the body's
colonize in the mucous cells reduction of already
excessive amounts of very
system bronchi requirement for oxygen;
of the nasopharynx narrowed
sticky airways
mucus which is
greatly increased muscular
irritation thus triggering
effort; may lead to exhaustion
Response byPatient
the autonomic
on AC ventilator: ory airway coughing
and respiratory failure
nervous system
TV:or influence
500 RR 22of(patients rate 24-26) (Can be very difficult to
FiO2 40 PEEP 5
anaphylatoxins/complement expectorate)
system
Bronchial glands produce
excessive amounts of very
sticky mucus which is
irritation thus triggering
coughing
(Can be very difficult to
Irritability, agitation All resolvable
expectorate)
Retractions with medical
Initially thin, white, or Severe infection: thick Grunting attention and
clear rust-colored or yellow- Abnormal labs results: 08/05 treatment
WBC 17.8, Platelets 472, BUN 100,
green mucus
creatinine 4.6
Initially thin, white, or Without
clear Severe infection: thick treatment
Dyspnea,
rust-colored or yellow- further
green mucus SOB complications:
May have nonproductive cough Irritability,
Related tocrying, fussiness
decreased
Tachypne Pleural effusion
leading to productive due to Retractions
lung capacity, O2
a Pleurisy
increased mucus production and Grunting
exchange, O2 saturation Empyema
breakdown of alveolar surfaces Fatigue, weak, Retractions
Dyspnea,
↑temp. Abnormal
Related tolabs results: Platelets,
decreased
SOB
↓appetite WBC,
lung capacity, O2 creatinine
Bands, BUN,

Bilateral exchange, O2 saturation

Resulting from
coarse lung increased fluid in All resolvable
Signs and sounds alveoli and segmental with medical
symptoms spaces in the lungs attention and
Bilateral
Pleuritic treatment
coarse lung
pain Resulting from
Signs and sounds increased fluid in Without
symptoms Pleuritic alveoli and segmental treatment
pain spaces in the lungs further
complications:
NANDA 1: Impaired Gas Exchange RT Ventilation-perfusion imbalance; Infiltrates in lungs, respiratory infection, bronchospasm AEB Abnormal breathing; rate, rhythm, depth,
dyspnea, hypoxemia, tachycardia, patient on ventilator.
Goals:
 Throughout my shift, 0700-1530 my patient will remain free from signs and symptoms of respiratory distress.
 By end of my shift patient will present with decreased adventitious lung sounds
 Throughout my shift, 0700-1530 my patient will continue to maintain vital signs and O2 saturation within normal limits.
 By end of my shift my patient will have a decrease in WBC counts.
Monitor:
 Throughout my shift; Assess patient’s lung sounds Q1hr and continuous O2 saturation. Lungs sounds presented with some inspiratory crackles, expiratory wheezes,
and diminished sounds in right and left lower fields; indicative of respiratory infection. O2 saturation maintained between 88 and 92% per MD orders
 Monitor vital signs; paying special attention to respiratory rate/effort, heart rate, and temperature. At time of admission, he was tachycardic and tachypneic indicating
impaired gas exchange and respiratory distress. Patient temperature was consistently normal; 98.8
 Monitor patient’s sedation level and titrate sedative—dexmedetomideen 0.4 mcg/kg/hr (27mcg/hr) continuous IV—as needed to achieve desired level of sedation.
 Monitor labs, especially white blood counts and ABG’s. WBC’s high—17.8, indicating an infection. ABG’s indicated slight metabolic acidosis.
 Monitor respiratory effort/work of breathing/accessory muscle use; nasal flaring.
 Monitor ventilator settings and patient response.
 Monitor the need for oral suction and in-line suction; mucus/sputum production, noting color/amount.
 Monitor radiology diagnostics/CXR to determine amount of fluids/infiltrates in lungs, noting locations and severity.

Manage:
 Perform physical assessments and collection of vital signs; compare with baseline to determine patient’s status and response to care.
 Administer Doxycycline IVPB, 100mg/100ml q 12hrs per orders to manage the infection and solumedrol, 60mg IVP q 24hrs for management of inflammations.
Continue to monitor lab trends.
 Collaborate and assist the Respiratory therapist managing the ventilator and making adjustments as needed/ordered in relation to patient needs.
 Collaborate with the Respiratory therapist in administration of Albuterol via nebulizer/ventilator, 2.5mg/3ml q 4hrs. Continue to monitor lung sounds, respirations, and
O2 saturation.
 Provide oral suction PRN and collaborate with RT/nurse for provision of inline suction.
 Maintain head of bed at a minimum of 30 degrees to help facilitate lung expansion and prevent aspiration of secretions.
 Maintain adequate hydration; ensure IV fluids are at ordered rate; Dextrose 5% in sodium chloride 0.9% solution at 50ml/hr continuously per orders
 Continually review labs and diagnostics for trends; to ensure patient is responding as desired to treatments, or for a need to review and modify care if patient status
not improving or deterioration.
Teach:
Patient unresponsive/sedated, but if awake and alert:
 Provide patient with simple explanation of why he was receiving medication and how it would help him.
 Teach patient/encourage use of Incentive spirometer Q10/hr while awake per MD orders
 Teach patient importance of position changes Q2hrs, and ambulating out of bed as tolerated/safe per orders.
 Encouraged patient to drink fluids and consume meals.
 Teach about modifiable risk factors; smoking cessation, diet, exercise, routine medical screenings, and management of non-modifiable factors; age, gender, history.
Evaluation: Throughout my shift, patient maintained O2 saturation of 89-92% per MD orders. Although patient’s respiratory rate remained high throughout my shift (20-26) his
wheezing and crackles had improved and RT was able to lower tidal volume by 5% without any noted desaturation by patient. Throughout my shift patient maintained vital signs
WNL, and lab and diagnostic results continued to trend towards positive results. Overall patient was responding to treatment and his condition was slowly improving.
NANDA 2: Risk for imbalanced body Temperature RT Illness; pneumonia, infection, medications; antibiotics
Goals:
 Throughout my shift patient will maintain normal body temperature; ideally between 98 to 99 degrees.
 Throughout the shift patient will remain free from signs and symptoms of infection
 All vital signs, lab results, and skin signs will stay within normal parameters.
 Patient will tolerate and respond well to pharmacological treatments.
 Throughout my shift, routine physical assessments will indicate all functions within normal parameters
 Patient’s environment will remain comfortable and conducive to patient’s thermo regulation and decreased stress.
Monitor:
 Monitor vital signs for any sudden deviation from normal; temperature, RR, HR, BP.
 Assess for risk factors such as an infection.
 Monitor skin for color, turgor, moisture, and temperature.
 Monitor medication administration and response to pharmacological treatments.
 Monitor all lab results especially WBC counts, UA, blood glucose.
 Monitor I &O; fluid balances.
 Monitor nutrition status and consumption.
 Monitor level of consciousness and mental status
 Monitor environment; ambient temperature, bedding, stressors
Manage:
 Frequent assessment of vital signs noting acute and gradual deviation from normal.
 Regular assessment for S/Sx of infection; ↑ body temperature, sweating, chills, agitation
 Administer Tylenol 650mg PO, Q4hr PRN as ordered for elevated temperatures.
 Administer Doxycycline IVPB, 100mg/100ml q 12hrs per orders for Tx/prevention of infection
 Administer Lantus 1-6 units—based on glucose level—subcutaneous Q24hrs to maintain proper glucose levels
 Routine physical assessments monitoring for changes in normal skin conditions, LOC, and mental status.
 Continually assess labs noting acute or gradual deviations from normal parameters.
 Ensure adequate fluids and nutrition; Continuous dextrose 5% in sodium chloride 0.9% solution at 50ml/hr and Nepro continuously via post-pyloric NG tube at 10ml/hr
with a goal of 50ml/hr per orders.
 Minimize environmental activity, ensure ambient temperature is comfortable, there is no excessive use of blankets and bedding is dry.
Teach:
Patient unresponsive/sedated, but if awake and alert:
 Teach patient about why we take regular vital signs and temperature readings.
 Teach patient about medication administration and indications
 Provide information regarding the importance of adequate hydration and nutrition in aiding the body’s defense mechanisms.
 Teach about modifiable risk factors; smoking cessation, diet, exercise, routine medical screenings, and management of non-modifiable factors; age, gender, history.
Evaluation: Although patient continued to have elevated WBC count of 13.3 during my shift, lab trends indicated a positive shift toward normal levels. Patient’s vital signs
including temperature and skin signs remained WNL throughout my shift. He did not exhibit any adverse reactions to medications, urine output remained WNL with an average
50ml/hr, and Nepro feeding rate was slowly increased to 30ml/hr as patient had minimal residuals. By end of shift patient was resting more comfortably with decreased signs of
agitation or new complications. Overall the care provided was meeting the plan of care and the desired outcomes.
NANDA 3: Risk for deficient fluid volume RT Decreased fluid intake, excess losses through normal routes, increased metabolic rate due to infection
Goals:
 Throughout my shift the patient will maintain balanced I & O numbers.
 Throughout my shift all labs and electrolytes stay within normal limits.
 Throughout my shift patient’s vital signs will stay within normal limits, with no gross drops in BP or spikes in temperature.
 Throughout my shift patient’s skin signs will stay within normal limits; color, turgor, temperature, and moisture.
 Throughout my shift the patient will remain free from signs and symptoms of infection; excessive mucus, elevated temperatures, and sweating.
Monitor
 Monitor hourly I & O results.
 Monitor for active fluid losses; diarrhea, vomiting, sweating.
 Monitor all labs results especially serum electrolytes.
 Monitor vital signs paying close attention to gross drops in blood pressure, increases in heart rate, and spikes in temperature.
 Monitor skin signs and temperature.
 Monitor mucus membranes.
 Monitor frequency of urine output and ensuring patient is outputting minimum 34ml/hr; patient is 68kg.
 Monitor IV fluid administration ensuring it is infusing at proper volume and rate as ordered.
Manage:
 Frequently collect and calculate fluid balances; Q1hr.
 Provide IV fluids as ordered; Continuous dextrose 5% in sodium chloride 0.9% solution at 50ml/hr anticipate a possible need for to increase or decrease fluids.
 Assess and interpret lab results and collaborate with MD as needed as needed to adjust fluid administration and/or electrolyte supplementation.
 Frequent assessment of vital signs ensuring all are within normal limits; especially BP, HR, and temperature changes.
 Monitor for diarrhea as a side effect of antibiotics.
 Nepro continuously via post-pyloric NG tube at 10ml/hr with a goal of 50ml/hr per orders.
 Administer Sevelamer 1,600mg PO Q8hrs per orders to maintain proper phosphate levels.
 Regular assessments of skin and mucus membranes.
 Provide calm, quite environment with low stimulation to promote rest and healing.

Teach: Patient unresponsive/sedated, but if awake and alert:

 Teach patient the importance of maintaining adequate hydration
 Teach patient about medication administration and indications
 Teach and encourage patient to consume adequate amounts of fluids—preferably water—throughout the day
 Encourage patient to report any decreases in urine output and/or bower movements.

Evaluation: Throughout my shift goal of maintaining adequate hydration and achieving adequate output was met as evident by stable vital signs, good skin signs, and pink, wet
mucous membranes. Administration of prescribed fluids was adequate as evident by I&O totals: average of 50ml of urine per hour and Nepro feeding rate was slowly increased
to 30ml/hr as patient had minimal residuals. Additionally, throughout my shift patient remained free from S/Sx of infection; elevated temperature, sweating, ↑WBC count,
↓BP, ↑HR, or excessive mucus production.
Mini NANDA 1: Ineffective breathing pattern RT inflammatory process AEB tachypnea, grunting, use of accessory muscles, ↑RR
Interventions:
 Assess respiratory function; respiratory rate, quality, work of breathing, use of accessory muscles i.e. nasal flaring.
 Assess for cough and sputum production, and ability to clear secretions.
 Assess lungs sounds for adventitious breath, diminished and/or absent breath sounds.
 Ensure continuous dextrose 5% in sodium chloride 0.9% solution at 50ml/hr per orders
 Maintain ventilator settings per orders and provide suction of airway PRN and per orders
 Collaborate with RT in administration of Albuterol, 3 ml via nebulizer Q 4hr.
 If patient was conscious and alert: teach S/Sx of respiratory distress and to report any findings even if they may not seem serious.
 Teach about medication administration and indications, and use of Incentive spirometer 10x/hr while awake per orders.

Mini NANDA 2: Risk for infection RT: Indwelling catheters and antibiotic therapy
Interventions:
 Identify risk factors for occurrence of infection (s): immunocompromised, age, invasive procedures pharmacology.
 Monitor and report labs values indicative of infection; WBC and/or differentials.
 Monitor peripheral IV—left AC—for signs of infiltration, leaking, or occlusions.
 Monitor ART line—right radial artery—for leakage, patency, pressure reading.
 Regularly assess venous and arterial access sites; ensure patency, lack of S/Sx of infiltration and/or leaking, clean, dry and intact
 Continuous dextrose 5% in sodium chloride 0.9% solution at 50ml/hr and Nepro continuously via post-pyloric NG tube at 10ml/hr with a goal of 50ml/hr per orders.
 Administer Doxycycline IVPB, 100mg/100ml q 12hrs per orders to manage the infection and solumedrol, 60mg IVP q 24hrs for management of inflammations.
 Monitor nutrition status: Ensure patient is receiving adequate fluids and nutrition; monitor I&Os and collaborate with MD.
 Stress proper had hygiene to family members and all caregivers.
 Monitor bowel movements for chronic diarrhea.
 If patient was conscious and alert: Educate on signs/ symptoms of infection and to notify if any symptoms occur; increase in temperature, sweats, chills, and diarrhea.
Discuss the importance of hand hygiene, nutrition, and hydration. Teach about medication administration and indications

Mini NANDA 3: Self Care Deficit; bathing, toileting, oral hygiene RT: Sedation/decreased level of consciousness AEB: Inability to carry out all basic hygiene functions.

Interventions:
 Perform regular oral hygiene for client using soft swabs and Peridex oral rinse Q12hrs per orders.
 Frequently monitor patient for bowel movements/ soiled bedding and provide care as needed.
 Ensure Foley catheter is patent, not leaking, and tubing is not dependent; flowing well.
 Perform fully body bed bath for patient at least every 24 hours.
 Provide clean gowns and bedding as needed to keep patient clean and dry.
 Frequent assessments of patient’s skin for feces, urine, and for any signs of compromised skin integrity.
 Reposition patient q 2 hours to reduce risk of skin breakdown.
Abnormal Labs
Test 08/05/2015 08/24/2015 Ref. Range Interpretation

WBC 17.8↑ 10.4 3.6-11 Response to infection

Platelet 472↑ 208 150-400 Compensation by the body;

inflammations, infection, anemia
Hgb 9.4↓ 6.7↓ 13-18 Patient has anemia

Hct 29.3↓ 20.8↓ 42-52 Patient has anemia

Calcium 7.4↓ 9-10.5 Patient has acute kidney injury;

reduced kidney function
BUN 37↑ *118↑↑ 8-25 Patient has acute kidney injury;
reduced kidney function
Creatinine 1.4 *4.1↑↑ 0.6-1.5 Patient has acute kidney injury;
reduced kidney function
Phosphorus **8.2↑↑ 2.5-4.5 Patient has acute kidney injury;
reduced kidney function
pH 7.34↓ 7.35-7.45 Slight metabolic acidosis; may be
related to patient’s diabetes.
PaCO2 38.3 35-45 Slight metabolic acidosis; may be
related to patient’s diabetes.
PaO2 88.7 80-100 Slight metabolic acidosis; may be
related to patient’s diabetes.
HCO3 20.3↓ 22-26 Slight metabolic acidosis; may be
related to patient’s diabetes.
*Patient began dialysis
**Patient receiving Sevelamer Discharge Planning

Patient is a single 83 year-old male Asian,

Patient Medications Buddhist. He lives alone with six cats. He has
Medication Dose Indication one family member, a niece that lives near him
and visits occasionally. Patient will need clear
Solumedrol 60mg IVP Q24hrs Anti-inflammatory
and concise discharge instructions in regards to
home medication regimen, self-care, and
Doxycycline 100mg IVPB Q12hrs Antibiotic
medical follow-up care; a hospital interpreter
Protonix 40mg IVP Q24hrs Anti-ulcer may be necessary to assure understanding of
instructions by patient, and to properly address
Lactulose 45ml NG Q24hrs PRN Laxative any needs, concerns, and/or questions the
patient may have. Due to patients advanced
Heparin 5000 units subcutaneous Q12hrs Anticoagulant/Antithrombotic age, lack of family, and mild cognitive
impairment, patient will benefit from in home
Labetalol 10mg IVP Q24hrs Antihypertensive assistance: chores, shopping, meal preparation,
self-care, medication regimen, and follow-up
Fentanyl 25mcg/hr IV continuous Opioid analgesic health visits to primary physician. Many of his
needs can be met by collaboration with case
Precedex 0.4mcg/kg/hr-27mcg/hr IV Sedative/adjunct to analgesic
manager and social services, and possible
Lantus 1-6 units subcutaneous Q24hrs PRN Hormone for diabetes referrals to in home care provider and/or home
nurse. Additionally, patient and his niece can
Sevelamer 1,600mg NG Q8hrs Phosphate binder benefit from a group meeting with social services
to determine the patient’s needs, how the niece
may help, and her overall role in her uncle’s life.
Furthermore, depending on patient’s status
ECG Strip attached to page 10 of care plan paperwork. upon discharge patient may be a candidate for
Based on attached strip, patient was in sinus tachycardia on lead 1 with what nursing home or assisted living facility. Patient
appears to be ST segment elevations on lead V4. During my shift patient will also benefit from routine follow-ups by social
remained in normal sinus rhythm. services and primary health care provider to
evaluate patient’s status and ongoing needs.
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