The given case study is about a 67 year old lady, who has been admitted in the emergency care with some severe symptoms related to the lung infection. The initial symptoms of the patient include occasional breathing trouble, headache cough, high fever and also loss of appetite. The initial level of diagnosis was similar to that of pneumonia. The patient is taking medicine that is intended to decrease the effect of the pneumonia.
The current assignment will aim to provide detail information related to the social and physiological background of the patient that will help the nurses to prepare a nursing plan for intervention measures for the patients. It is important to have a particular set of nursing goals in order to deal with every clinical problem that are encountered by the patient. The report will also aim to provide a critical assessment of each type nursing care that is provided to the patient and the significance of that interference method in background of the clinical state of affairs of the patient. The assignment is done by maintain full confidentially to ensure that no private and personal information about the patient is being leaked in the public. The recommendations are also provided that can help in the procedure of ahead of the future clinical confronts that the patient encountered and can also assist in the procedure of the future action that need to be provided to the patient. There are also few risks and hazards that are involved in the overall process of the nursing care, which are also highlighted among the patients.
At the initial stage it is vital for the nursing care person to collect detail background information about the clinical history of the patient that can help to deal with understanding the current situation of the patients that can help in the overall process of making future nursing care plan for the patient.
The current physiological condition of the patient also needs to be evaluated that can help to deal with the challenges that are encountered by the patient. The disease of pneumonia is caused due to the swelling of lungs that occurs in the tiny air sacs located within the alveolar cavity of the lungs. The tiny air sacs that are present are filled with the alveolar fluid.
The lady is currently suffering from the physiological conditions that are similar to that of pneumonia and therefore, she is suffering from a disease that has the ability potential to cause infection in all the various vital respiratory organs. During the time she has been admitted in the emergency department symptoms like dry cough, high fever, and low SpO2 are diagnosed from her condition.
The term SpO2 is the indication of peripheral oxygen saturation level which helps to measure the total amount of oxygen present within blood. This thing can be measured with the help of pulse oximetry. Lower level of oxygen saturation with the arterial blood can cause breathing trouble and is generally caused from the lung infection. The pulse rate generally drops significantly with lower level of SpO2. For a normal condition the SpO2 is generally 96 to 100%. Hence, for old lady in the given case study the SpO2 level is 95, which is lower than the normal value and thereby is believed to be the cause of breathing trouble.
The rate of respiration was calculated to be of 36 breaths per minute, which is regarded at the higher side. The normal breathing rate for the human is regarded as to be 12-20 breathes per minute, which is generally raised during the time of respiratory infection and disease. In case of child however, the breaths varies from 25-50 per minute due to the fact that they required extra oxygen for all their biological activity. The higher breathing rate of the old lady in the given case is therefore the indicator of breathing trouble that she is facing due to the pneumonia. She also had to take more breaths due to the fact that oxygen level of her body has been significantly lower.
The blood pressure of the lady is also at higher stage due to the fact that heart rate has increased that is needed to pump more blood within the body. For a normal individual the blood pressure is generally at 120/80. However, in case of the lady, the blood pressure was diagnosed to be 170/85, which is generally at the higher level. Hence this is cause of dizziness within the old lady. This type of disease is generally of chronic in nature and can cause permanent injure to the composition of the patient.
The body temperature of the patient was detected to be 37 degree Celsius, which is slightly higher than the normal body temperature. In normal the body temperature is about 36 degree Celsius, hence the patient is suffering from slightly high body temperature that has caused loss of appetite among the patient. The pulse rate is diagnosed to be normal of the patient at this 75 beats per minute that is a little above the usual owing to the age of the patient. This information that is obtained from the diagnosis will be important to prepare proper intervention measures for the patient.
The lady is also currently taking few medications that include azithromycin, that is aimed to deal with all types of bacterial infection and this type of medication is generally taken on the oral basis. Few of the major side effects that the lady can suffer due to taking of this medication include diarrhoea and stomach that ultimately leads to vomiting. There are also long term side effects that include tiredness and loss of appetite that is evident in case of the lady in the case study. It is important that careful dosage of the medicine is given to the lady that will help to ensure that consequences of the side-effects are minimized.
Ceftriaxone is another antibiotic medicine that is being taken by the lady that helps in the matter of coping with the result of the bacterial infection. This type of medication is mainly used for the symptoms like the chest pain and cough, which are few of the common symptoms related to the pneumonia. In this case, also the diarrhoea is one of the usually happening diseases that are one of the main side effects of the medication that is being taken.
It is important for the medical workers to take a detail note of all the medications that are taken by the lady in order to prepare the future treatment plan of the lady.
The social backdrop in order to the patient is also significant that is necessary to make the interference plan that is one of the most significant part of that is needed to make the intervention plan for the pneumonia patient. In the given case, the old lady comes from the background of the business family and hence, it can be evident that the financial condition of the family is stronger and hence, it is possible for them to afford the higher cost of medical cost that is needed for her condition. The lady also has four children and all of them live separately, living alone. At present she stays with her husband and he is responsible for fulfilling all the medical needs of the patient. The patient has a poor family background owing to the fact that she is not getting any social support from her children, which can deprive her from the social support that is needed in this age for all individual.
The lady also comes from the family background, where there have been strong cases of pneumonia. The brother in law of the lady has been suffering from the case of pneumonia and has therefore created an unhealthy environment that had resulted in the increased risk of pneumonia within the family of the old lady. Hence, the poor record in the social background of the lady has increased the risk of pneumonia.
It is important to identify the key areas of nursing problems that will help in the procedure of preparing intervention plan for the lady who is suffering from pneumonia. The health challenges that survive in the action of pneumonia are the major nursing challenges that are faced by the health workers. Due to the infectious nature of the pneumonia disease is important for the nurse to ensure that the patient is being kept separately in order to minimize the risk of spreading of the infection (Quinn et al. 2014).
One of the major challenges that are encountered by nurses dealing with patient who are affected by infectious disease is the individual level of needs that is required for full revival of the patient. In many, it has been seen that the nurse ignores the information of the preceding medical files of a patient. Especially during the time of medical emergency one of the major challenges of the nursing is to collect sufficient information to provide accurate treatment according to the clinical condition of the patient. Hence, in most of the cases the treatment is done using wrong or inaccurate information (McHugh and Ma 2013). This in was the greater risk of wrong medical treatment that can worse the condition of a patient. The long-term nursing outcomes are also overlooking during the time of medical emergency.
In the given case for the patient is being admitted to the emergency department one of the major risk that are involved is the lack of medical history background of the patient and the information that is needed to provide the immediate future treatment. Due to the infectious nature of pneumonia the nurse and other medical workers itself are at the risk of catching hold of the disease.
Due to the infectious nature of the pneumonia disease the nurse can face challenge to maintain a clean and healthy environment within the Healthcare Unit which can help to reduce the time of recovery of the patient. The acute pain that is caused due to the symptoms of Pneumonia can also be a major challenge to the nurse. The lack of awareness among the patients can also cause huge challenge to the patients that are responsible for the risk that can compromise on the overall level of safety among the patients (Carthon et al. 2015).
There are various supportive measures that are needed in order to deal with pneumonia patient. Humidified oxygen therapy is one of the important nursing practices that can help the patient to recover from lack of oxygen within the blood supply and also help in the process of breathing trouble. It is important for the nurse to recommend the patient to take adequate amount of fluid and also proper bed rest in order to deal with the breathing trouble and chest pain that is one of the major symptoms of pneumonia (Nakagawa et al. 2014).
As mentioned in the above section spreading of infection is one of the major risks that are involved in case of pneumonia intervention for the nurse. Hence in this context it is important to maintain a full clean and healthy environment in and around the patient in order to minimise the risk of spreading of infection (Sjögren et al. 2016). The risk of infection can also be prevented by providing sufficient information to the patient care department and encouraging them to practice the important steps of hygiene. The use of antiseptic items in order to take care of the patient can help to deal with the infection that is caused. Promoting the Airway clearance is one of the effective ways that can help to maintain the clean environment in and around the area of the patient care that can help to minimise the risk of infection spreading (van der Maarel?Wierink et al. 2013).
It is also important for the nurse to ensure that proper diet of the patient is maintained. Due to the fact that loss of appetite occurs in case of pneumonia it is important for the nurse to have alternate ways to ensure that all the nutrients and fluid are being in taken to the patient. This can ultimately help to ensure that, the immune system of the patient is improved in order to deal with the challenges of patient care.
Providing ventilation care in case of severe condition can also help the patient to deal with breathing trouble and lack of oxygen supply within the blood cells (Ishida et al. 2015).
One of the major challenge that are encountered by the nurses in the given situation is the lack of information due to shortage of time what is needed to provide proper and accurate medical care treatment. In order to deal with this challenge it is important for the medical workers to have proper exposure and experience to deal with patients of the emergency care. Few of the key skills that includes in this case is the ability to act efficiently and provide treatment with minimum information that can be collected during the time of emergency care. Prioritizing the needs according to the actual condition of the patient is one of the important parts to deal with the care that is needed for the patient (Gulanick and Myers 2013).
It is important to note in this context that pneumonia can be caused due to various pathogenic activities that include virus bacteria or even fungal infection. It is therefore important for the Healthcare workers to identify the actual cause of pneumonia and provide medications. It can be a high risk of Side Effects if the medications are provided without properly diagnosing or assessing the symptoms that are related with pneumonia in case of each and every particular patient (Teramoto et al. 2015). The dosage of the medication also needs to be accurately measured according to the clinical condition of the patient in order to avoid the harmful consequences of Side Effects that are associated with all types of antibiotics.
There are several areas of improvement that needs to be adopted in order to reduce the time of recovery and also risk of infection spreading from the patient who is suffering from the symptoms of Pneumonia. The diagnosis method needs to be adopted infrequent time interval in order to properly get detailed information about the clinical condition of the patient. The intervention measures that are provided also need to be modified according to the changing clinical condition of the patient.
Measurement of the total count of white blood cells in the blood is one of the major indicators of the immunity strength within an individual. It is therefore important to include the test of WBC count within the blood in order to properly access the information about the condition of immune system of the patient that can help to deal with the pathogens of pneumonia (Scannapieco and Shay 2014).
It is also important for the patient to have a proper diet chart that needs to be suggested according to their clinical condition that can help to improve upon the condition of immune system. Proper information about the immunization status is also important as it helps to have proper intervention step to avoid incomplete immunization among the patient care. It is also important for the nurse to properly monitor the actual signs and symptoms of infection. The colour of respiratory secretions can be regarded as one of the major indicators to properly evaluate the effect of infection that is occurred within the lungs and alveolar section (Sakoda et al. 2014). Proper urine test also needs to be implemented that can help to identify the pathogens that are responsible for the infection. For example it cloudy and foul smelling urine is one of the indicated that the infection has spread to the urinary bladder which immediately needs to be intervene.
Overall it is important to ensure that all the key skills are being incorporated within the nurse and other Healthcare workers who are responsible to take care of the pneumonia patient.
The critical analysis and evaluation of the nursing care that are planned for the pneumonia patient is an important part that helps to fix up on the time that is needed to take care of the patient. This can help to make sure that only the best nursing care are being provided to the patient that can minimise the total time of recovery of the patient (Juthani-Mehta et al. 2014).
It is also possible to avoid all types of medical errors and risks that are involved with the disease and all other symptoms related to pneumonia. It is important to have a fixed goal within a definite period of time that is needed to fully recover the condition of the patient. Appropriate care requirements to be provided by correctly and precisely evaluating the condition of individual patient. It is also important not to have a generalized theory of nursing care that will not help to deal with the individual challenges that are encountered by the patient of pneumonia.
The cultural aspect is also one of the important elements of nursing care that help the medical workers to fulfil the needs and demand of individual patient according to their comfort. The overall planning of nursing intervention also needs to be evaluated in order to ensure that Full support is being provided to the patient (Hollaar et al. 2017). It can also help to provide the mental support that is needed for the patient to quickly recover from the nursing care and reduce the effect of adverse symptoms associated with pneumonia.
Conclusion
In the given case the old lady who is suffering from pneumonia has a poor background of family history. She is also not getting proper social support from his family members which can help to provide proper mental support to the patient. It is important to have proper nursing care according to the need of the patient in order to minimise the adverse effect of pneumonia. Proper diagnosis and collecting detail clinical information about the situation of the patient is crucial in order to deal with the challenges.
Reference:
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Gulanick, M. and Myers, J.L., 2013.Nursing Care Plans-E-Book: Nursing Diagnosis and Intervention.Elsevier Health Sciences.
Hollaar, V.R., van der Putten, G.J., van der Maarel-Wierink, C.D., Bronkhorst, E.M., de Swart, B.J., de Baat, C. and Creugers, N.H., 2017. Nursing home-acquired pneumonia, dysphagia and associated diseases in nursing home residents: A retrospective, cross-sectional study. Geriatric Nursing.
Ishida, T., Tachibana, H., Ito, A., Ikeda, S., Furuta, K., Nishiyama, A., Noyama, M., Tokioka, F., Yoshioka, H. and Arita, M., 2015. Clinical characteristics of pneumonia in bedridden patients receiving home care: A 3-year prospective observational study. Journal of Infection and Chemotherapy, 21(8), pp.587-591.
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Nakagawa, N., Saito, Y., Sasaki, M., Tsuda, Y., Mochizuki, H. and Takahashi, H., 2014.Comparison of clinical profile in elderly patients with nursing and healthcare?associated pneumonia, and those with community?acquired pneumonia.Geriatrics & gerontology international, 14(2), pp.362-371.
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Sakoda, Y., Ikegame, S., Ikeda-Harada, C., Takakura, K., Kumazoe, H., Wakamatsu, K., Nakanishi, Y. and Kawasaki, M., 2014. Retrospective analysis of nursing and healthcare-associated pneumonia: analysis of adverse prognostic factors and validity of the selection criteria. Respiratory investigation, 52(2), pp.114-120.
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