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 o

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, ba
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 cou
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 responsecoughingand the immune response will prevent the aspirated organisms from entering the lungs and causing the infec
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 an
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.

Risk Factors for Pneumonia:

* People older than age 65
* Weakened or suppressed immune system
* Chronic illness
* Weak cough reflex
* Exposure to chemicals, pollutants, and toxic
fumes
*Hospital stays
* Placement on a ventilator
* Crowded living conditions
* Exposure to airborne droplets
* Poor nutrition
* Allergies or asthma
* Debilitated state

Admission History
Chief Complaint
Fatigue, weakness, poor
Demographics
appetite
Pt. Initials: RO Room: 7224 Gender/Race/Age: M,
Admitting Diagnosis
Asian Buddhist
83
Leukocytosis,
pneumonia,
abnormal
Labs:
Ht: 166.4cm Wt: 68kgWBC 17.8,
Hgb 9.4, Hct 29.3, Plt 472
Allergies: NKA Code Status: Full Advanced
Current
Diagnoses
Directives
: None
Pneumonia, Respiratory
Precautions:
failure Standard
Diet: Nepro via post-pyloric NG tube
Activity: Bed rest; patient sedated

Clinical Manifestations of Pneumonia:

* Coughing; may be productive or nonproductive
* Shortness of breath
* Tachypnea
* Hypoxemia
* Adventitious lung sounds
* Fever
*Sweating and chills
* Dehydration
* Malaise
* Muscle aches
* Pleuritic chest pain
* Pulmonary consolidation; crackles/course lung
sounds
* Retractions
* Grunting
* Nausea and vomiting

Cultural
Date of Considerations:
Admission: 08/05/2015

Asian, Buddhist generally do not make eye contact while

conversing and often look down instead. They prefer a larger
area of personal space than western cultures. It is considered
disrespectful to position oneself higher than the oldest member
of the family. It is generally acceptable to greet someone with a
handshake or by bowing the head. A loud tone of voice means
that you are showing anger. Buddhist prefer to speak in a very
calm and indirect manner. Is common for Buddhist to not express
their feelings or emotions when communicating.
Rice is the main food staple in Vietnamese culture along with
vegetables, bread, and noodles. Cold/iced beverages are not
acceptable and after childbirth only warm or hot water should to
be consumed. Lactose intolerance is common so good food
sources of calcium include tofu, bok- choy, mustard greens, and
broccoli.
Patient was sedated, however all of the above would have been
considered and accommodated for my patient had I interacted
with him. Additionally patient was a full code and without
advanced directives which were noted in his chart/EMR.
Additionally, patient does not have a large family, and had no
visitors. He only has a niece that lives near his home that visits
him occasionally. Thus patient will require many community and

Labs
Hematology
Chemistry profile
ABGs
Diagnostics
*Chest X-rayPersistent
pneumonia
*Urine and blood
cultures
*

Medical Hx
*Emphysema
*Diabetes-diet
controlled
*Anemia
*Tobacco abuse
*AAA without rupture
*Hyperlipidemia
*Postherpetic
Neuralgia
*Mild cognitive

* Poor appetite
* Irritability/agitation
* Headache
* Abnormal labs results: Platelets, WBC, Bands, BUN, creatinine

Pneumonia

Bacterial
infection:
Streptococcus
Streptococcus

Doxycycli
ne
100mg
IVPB
Q12hrs
Solumedr
ol
WBC 17.8

Viral Infection:
Influenza
Adenovirus
Respiratory
Syncytial
NANDAS
Purple

Fungal Infection:
Pseudomonas
Candida

Outcome/Goals Pink
Results - Orange
Organisms enter
Interventions
Green

and colonize in the

mucous cells of the
nasopharynx

Congestion of bronchioles,
necrosis and sloughing of
bronchial mucous membranes;
formation of peribronchial
abscesses and pneumatoceles
(air filled cavities)

Lobar Pneumonia
(Usually
pneumococcal)
1) Infection
engorgement with
effusion of blood and
serum into alveoli in one
or more lobes
(Patient WBC 17.8 on
2) Alveoli infiltrated
with red blood cells,
fibrin, and
3) Consolidation of
leukocytes and fibrin
within the affected
areas occurs.
(08/18CXR: Ground
glass opacities

Clinical

Host defense mechanisms fail to

prevent organisms from
migrating into lower respiratory
tract; lower respiratory tract
infection can begin in one to

Bronchopneumonia
(Usually
Staphylococcal)
Doxycycli
ne
100mg
IVPB
Q12hrs
Solumedr
ol

Medications Red
Labs/Diagnostic

Mucopurulent
exudates
collect in
terminal
bronchioles
Congestion of
bronchioles,
necrosis and
sloughing of
Small airway
obstructions/cong
estion, air
trapping, and
increased airway
resistance.

Interstitial Pneumonia
(Usually viral or
streptococcal
Inflammation of
walls of alveoli,
bronchi and
bronchioles
Atelectasis
and or
bronchosp
asms

Initial diagnosis by CXR

findings; patchy ground
glass opacities throughout
right lung suggestive of
pneumonia.

Respiratory
infection

Bronchial
constriction/contractio
n of the smooth
muscle of the bronchi

4) Formation of

peribronchial
Response
by the
abscesses
and
pneumatoceles
autonomic nervous
(air filled
system or influence of
cavities)
anaphylatoxins/complem

Signs and
symptoms

Bronchial glands
produce excessive
amounts of very
sticky mucus which
is irritation thus
triggering coughing
(Can be very difficult
to expectorate)

respiratory failure

Irritability, agitation
Retractions
Grunting
Abnormal labs results: 08/05
WBC 17.8, Platelets 472,
BUN 100, creatinine 4.6

Severe infection:
thick rust-colored
or yellow-green
mucus

May have nonproductive

cough leading to productive
due to increased mucus
production and breakdown
of alveolar surfaces

Mucosa become
swollen and
inflamed, greater
reduction of already
narrowed airways

Greater effort needed to

move air in order to
meet the body's
requirement for oxygen;
greatly increased
muscular effort; may
lead to exhaustion and

Patient on AC ventilator:
TV: 500
RR 22 (patients
rate 24-26)
FiO2 40
PEEP 5

Initially thin, white,

or clear

Acute narrowing and

obstruction of the
respiratory airway

Dyspne
a, SOB
Tachyp
nea
Fatigue,
weak,
temp.

Bilateral
coarse
lung
Pleuritic
pain

Related to
decreased lung
capacity, O2
exchange, O2

Resulting from
increased fluid in
alveoli and
segmental spaces
in the lungs

All resolvable
with medical
attention and
treatment
Without
treatment
further
complication
s:
Pleural
effusion
Pleurisy
Empyema

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 patients 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 patients sedation level and titrate sedativedexmedetomideen 0.4 mcg/kg/hr (27mcg/hr) continuous IVas needed to
achieve desired level of sedation.

Monitor labs, especially white blood counts and ABGs. WBCs high17.8, indicating an infection. ABGs 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 patients 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 patients 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

Patients environment will remain comfortable and conducive to patients 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 unitsbased on glucose levelsubcutaneous 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 bodys 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. Patients 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
Throughout
Throughout
Throughout
Throughout
sweating.

my
my
my
my
my

shift
shift
shift
shift
shift

the patient will maintain balanced I & O numbers.

all labs and electrolytes stay within normal limits.
patients vital signs will stay within normal limits, with no gross drops in BP or spikes in temperature.
patients skin signs will stay within normal limits; color, turgor, temperature, and moisture.
the patient will remain free from signs and symptoms of infection; excessive mucus, elevated temperatures, and

Monitor

Monitor
Monitor
Monitor
Monitor
Monitor
Monitor
Monitor
Monitor

hourly I & O results.

for active fluid losses; diarrhea, vomiting, sweating.
all labs results especially serum electrolytes.
vital signs paying close attention to gross drops in blood pressure, increases in heart rate, and spikes in temperature.
skin signs and temperature.
mucus membranes.
frequency of urine output and ensuring patient is outputting minimum 34ml/hr; patient is 68kg.
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.

Teach:

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.
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 fluidspreferably waterthroughout 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 IVleft ACfor signs of infiltration, leaking, or occlusions.

Monitor ART lineright radial arteryfor 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,

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 patients 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
08/05/20
15
WBC
17.8

08/24/20
15
10.4

Ref. Range

Interpretation

3.6-11

Response to infection

Platelet

472

208

150-400

9.4

6.7

13-18

Compensation by the body;

inflammations, infection,
anemia
Patient has anemia

29.3

20.8

42-52

Patient has anemia

7.4

9-10.5

Patient has acute kidney

injury; reduced kidney
function
Patient has acute kidney
injury; reduced kidney
function
Patient has acute kidney
injury; reduced kidney
function
Patient has acute kidney
injury; reduced kidney
function
Slight metabolic acidosis;
be related to patients
diabetes.
Slight metabolic acidosis;
be related to patients
diabetes.
Slight metabolic acidosis;
be related to patients
diabetes.
Slight metabolic acidosis;
be related to patients
diabetes.

Hgb
Hct
Calcium
BUN

37

*118

8-25

Creatinin
e

1.4

*4.1

0.6-1.5

Phosphor
us

**8.2

2.5-4.5

pH

7.34

7.35-7.45

PaCO2

38.3

35-45

PaO2

88.7

80-100

HCO3

20.3

22-26

*Patient began dialysis

**Patient receiving Sevelamer

may
may
may
may

Discharge Planning

Patient Medications
Medicatio
Dose

Indication

n
Solumedr

60mg IVP Q24hrs

Anti-inflammatory

ol
Doxycycli

100mg IVPB Q12hrs

Antibiotic

ne
Protonix

40mg IVP Q24hrs

Anti-ulcer

Lactulose

45ml NG Q24hrs PRN

Laxative

Heparin

5000 units subcutaneous

Anticoagulant/Antithrom

Labetalol

Q12hrs
10mg IVP Q24hrs

botic
Antihypertensive

Fentanyl

25mcg/hr IV continuous

Opioid analgesic

Precedex

0.4mcg/kg/hr-27mcg/hr IV

Sedative/adjunct to

Lantus

1-6 units subcutaneous

analgesic
Hormone for diabetes

Sevelame

Q24hrs PRN
1,600mg NG Q8hrs

Phosphate binder

r
ECG Strip attached to page 10 of care plan paperwork.
Based on attached strip, patient was in sinus
tachycardia on lead 1 with what appears to be ST
segment elevations on lead V4. During my shift patient
remained in normal sinus rhythm.

References

Patient is a single 83 year-old male

Asian, Buddhist. He lives alone with six
cats. He has one family member, a
niece that lives near him and visits
occasionally. Patient will need clear and
concise discharge instructions in
regards to home medication regimen,
self-care, and medical follow-up care; a
hospital interpreter may be necessary
to assure understanding of instructions
by patient, and to properly address any
needs, concerns, and/or questions the
patient may have. Due to patients
advanced age, lack of family, and mild
cognitive impairment, patient will
benefit from in home assistance:
chores, shopping, meal preparation,
self-care, medication regimen, and
follow-up health visits to primary
physician. Many of his needs can be
met by collaboration with case
manager and social services, and
possible referrals to in home care
provider and/or home nurse.
Additionally, patient and his niece can
benefit from a group meeting with
social services to determine the
patients needs, how the niece may
help, and her overall role in her uncles
life. Furthermore, depending on
patients status upon discharge patient
may be a candidate for nursing home

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Dirksen, S. R. (2011). Clinical companion to Medical-surgical nursing: Assessment and management of
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Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nurse's pocket guide: Diagnoses, prioritized
interventions, and rationales (12th ed.).
Lewis, S. M. (2011). Nutritional problems. In Medical-surgical nursing: Assessment and management of
clinical problems (8th ed., p. 931). St. Louis, MO: Elsevier/Mosby.
McCance, K. L., & Parkinson, C. (2010). Study guide for Pathophysiology, the biologic basis for disease in
adults and children, sixth edition (6th ed.). St. Louis, MO: Mosby.
Stuart, B. K., Cherry, C., & Stuart, J. (2011). Pocket guide to culturally sensitive health care. Philadelphia,
PA: F.A. Davis Co.