A client who is 79-year-old man developed a wet-productive cough six days prior to being seen in the clinic. The client suspects he might have PNEUMONIA. The sputum is thick and yellow with streaks of blood
A client who is 79-year-old man developed a wet-productive cough six days prior to being seen in the clinic. The client suspects he might have PNEUMONIA. The sputum is thick and yellow with streaks of blood. He developed chills, shaking, and overwhelming fatigue with the cough and fever that started six days ago. The client lost 15 lbs over the past 2 months but claims he did not lose his appetite. “I am worried I have PNEUMONIA” Past history reveals that he is a smoker 1 pack/day for 15 years. He sleeps on 4 pillows at night. The patient is a retired machinist who has been treated for mild hypertension and bronchitis in past history.
OBJECTIVE:
A client is an elderly man who appears tired and underweight. Vital signs are as follows: blood pressure 152/90, apical heart rate 112/minute and regular; respiratory rate 24/minute and somewhat labored, temperature 102.6 F oral. His complexion is sallow. He coughs continuously. Sitting in a chair, he leans to his right side, holding his right chest with his left arm. Examination of the neck reveals a large, non-tender hard lymph node in the right supraclavicular fossa. Both lungs are resonant by percussion except that the right mid-anterior and right mid-lateral lung fields are dull. Auscultation reveals bilateral diminished vesicular breath sounds. Bronchial breath sounds, rhonchi, and late inspiratory crackles (are heard) in the area of the right mid-anterior and right mid-lateral lung fields. The remainder of the lung fields is clear. Percussion and auscultation of the heart revealed no significant abnormality. Examination of the fingers shows clubbing.
LABORATORY in ER: WBC 19,000/mm3; neutrophils 70%, bands 15%, lymphocytes 15%.
Fill in the blanks and complete the questions below.
PLEASE FILL IN THE BLANKS AND COMPLETE THE QUESTIONS BELOW WITH REFERENCES FOR ALL SECTIONS.
Q1. ASSESSMENT [this is the 1) medical and 2) nursing diagnosis (NANDA sentence)].
1)
2)
2 What is the Plan for treating Pneumonia?
3 What is the diagnostic?
4 What is the Therapeutic?
5 How do you educate the client?
6. Are there other questions in subjective that should be asked?
7. Are there other objective findings you would like detailed for further care of the patient?
8. Is there anything you want to do before entering this room?
9. Is there anything you want to do before leaving this room—more than 1 answer here?
10. How did this assignment increase your knowledge related to respiratory concerns?
