careplan 237-- reu | Pneumonia

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NURSING CARE PREPARATION Student Name: Kayt Geyer Date of Care: 02/02/17 Unit/Room Number: REU 237 Date of Admission: 01/26/2017 Age: 75 Ethnic/Cultural Preferences: Gender: Female Allergies: Iodinated Contrast Media- IV DYE, Erikson’s Developmental Level: Ego Avandia integrity VS despair.
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  NURSING CARE PREPARATION Student Name: Kayt Geyer Date of Care: 02/02/17 Unit/Room Number: REU 237 Ae: 7! Gender: ema#e Eri$%on&% De'e#o(menta# )e'e#: Eo interity *S de%(air+ Date of Admi%%ion: 01/2,/2017 Et-ni./Cu#tura# referen.e%:A##erie%: odinated Contra%t edia * DE4A'andiaCode Statu%: u## .ode+ rimary Diano%i%:C5 4 5ea#t- .are a%%o.iated (neumonia+ Comorbiditie%:C5 4 .e##u#iti%4 atria# 6bri##ation4 -y(er#i(idemia+ Di%.-are #an add day of .#ini.a#8:nterated at-o(-y%io#oy 9-at i% oin on 9it- your (atient at t-e .e##u#ar #e'e# for t-e -ea#t- .ondition4 no more t-an t-ree (ae% in #ent-4 t-ird (ae i% t-e referen.e (ae87!yearo#d fema#e 9-o -a% e(erien.ed a .ou- and dy%(nea o'er t-e (a%t fe9 9ee$%+ ;-e (atient .urrent#y #i'e% in a nur%in fa.i#ity 9-ere %-e -a% .ontra.ted (neumonia+ <-en in=ammation in air %(a.e% of t-e #un% o..ur% ba.teria4 funi or 'iru%e% .an be.ome tra((ed and in return .au%e% ro9t- and %(read% to an infe.tion of t-e #un% $no9 a% (neumonia+ ;-i% .au%e% an ine>e.ti'e air9ay and a% e.-ane+ neumonia .an be .#a%%i6ed in di>erent 9ay%+ t i% often referred to -o9 t-e infe.tion 9a% a.?uired+ ;-ere i% .ommunitya.?uired (neumonia and -o%(ita# a.?uired (neumonia+ Community ba%ed (neumonia id mo%t .ommon form of (neumonia and i% de'e#o(ed out %ide of t-e -o%(ita# or -ea#t- fa.i#itie%+ 5o%(ita# a.?uired (neumonia o..ur% 9-en a (atient i% a#ready -o%(ita#i@ed and or under t-e .are of a -ea#t- fa.i#ity from a (rior .ondition+ ;-i% (arti.u#ar ty(e of (neumonia .an be more danerou% % and fata# to a (atient due to t-e (atient a#ready bein immune .om(romi%ed+  ;-e (atient 9a% admitted to t-e ER 'ia ambu#an.e due to in.rea%ed .om(#aint% of %-ortne%% of breat-4 .ou- and (ain+ ;-e (atient -a% a -i%tory of .one%ti'e -eart fai#ureand (eri(-era# edema of t-e #o9er etremitie% 9a% noted u(on admi%%ion+ ;-e (atient 9a% i'en )a%i ine.tion to %tart diure%i% due to -er -i%tory of C5 + ;-e (atient 9a% immediate#y %tarted on 'an.omy.in and @o%yn+ B#ood .u#ture% 9ere ordered a% #on 9it- %(utum %am(#e% a% 9e##+ B#ood .u#ture% returned 9it- no %in of %(e.i6. ba.teria# ro9t-4 a#t-ou- %ti## 9aitin to obtain %(utum %am(#e%+ atient i% .ontinuin on 9it-  *an.omy.in and o%yn+ <e 9i## 9ant to monitor (atient% bo9e#% 9it- t-e%e t9o antibioti.% edu.ate (atient on im(ortan.e of tryin to add yourt to -er diet a% 9e## to -e#( (romote -omeo%ta%i% in -er %toma.-+ t i% noted t-at t-e (atient% .ou- -a% de.rea%ed and %-e re(ort% de.rea%e in (ain and -er %-ortne%% of breat- -a% de.rea%ed a% 9e##+ <e 9i## 9ant to monitor -er 02 %aturation% and re%(iration rate% due to -er .02 #aboratory 'a#ue%+ <e are .urrent#y %ti## tryin to o> #oad =uid from t-e (atient and 9ant to monitor =uid inta$e and edema due to -er -i%tory 9it- C5 + A#t-ou-4 o> #oadin =uid fa%t and .ontinua##y .an be danerou% for t-e (atient a% 9e##+ 5er %odium #e'e#% and (ota%%ium #e'e#% -a'e dro((ed+ )o9 (ota%%ium #e'e#% .an #ead to mu%.#e damae4 9ea$ne%% and often -eart (a#(itation%+ ;-e (atient -a% a -i%tory of atria# 6bri##ation %o 9it- a #o9 (ota%%ium #e'e# t-i% (#a.e% t-e (atient at an e'en -i-er ri%$ for any (a#(itation% or -eart arr-yt-mia%+ Works Cited Functional Anatomy and Biochemicals + 20138+ Uni'er%ity of G#a%o94 Uni'er%ity of Strat-.#yde4 G#a%o9 Ca#edonian Uni'er%ity and t-e Uni'er%ity of ai%#ey+ Su((orted by t-e S.otti%- 5i-er Edu.ation undin Coun.i#8 Retrie'ed an 14 201,4 from 5i( ra.ture% : -tt(://999+#a+a.+u$/t/F7dfb#%/6#e%/fab/tutoria#/.#ini.a#/or-i(+-tm#.Can.e4 S+ E+ Understanding Pathophysiology   *o#+ !t-8+ *+ )+ D4 Ed+8 Sa#t )a$e4 Uta-: E#%e'ier+Data Co##e.tion Re.ord ea.t#y 9-at i% 9ritten on t-e (er%ona# information %-eet Ha$a KardeI+ Any a%%e%%ment/e#aboration %-ou#d be made on t-e a%%e%%ment %-eet8:Diet ;y(e8: 2 G Sodium+ *  #uid ty(e4 rate4 a..e%% ty(e8:eri(-era# *4 Ri-t 9ri%t4 20 G4 %orba 'ie9 dre%%in4 Sa#ine )o.$ed+ J D order/Nur%in rder/ re?uen.y8: Stri.t / do.umentation e'ery 12 -our%+ CBG e%/No4 fre?uen.y8: AC5S a## Ri%$/Safety re.aution% e%/No8: Standard (re.aution%+ A.ti'ity <-at i% ordered8: A% to#eratedL 12 (er%on a%%i%t+ <ound Care e%/No8: e% Wound Protocol:  RU;NE <ound )o.ation: ))E media# .a#fL Stae: N/AL Sour.e: abra%ionL Dire.tion%: C#ean%e 9it- 9ound .#ean%er4 rin%e 9it- norma# %a#ine+ Co'er 9it- me(i#e border+ C-ane e'ery ot-er day and (rn+ 0700 E'ery ot-er Day Wound Protocol:  RU;NE <ound )o.ation: ) #atera# #o9er #e4 R (o%terior and #atera# #o9er #eL Stae: N/AL Sour.e: yen e%/No4 De#i'ery met-od4 -o9 mu.-8: Room air+  arteria# in%uM.ien.yL Dire.tion%: C#ean%e 9it- 9ound .#ean%er4 rin%e 9it- norma# %a#ine4 6## 9it- eroform au@e4 .o'er 9it- me(i#e border+ C-ane e'ery ot-er day and (rn+ 0700+++ Wound Protocol:  RU;NE <ound )o.ation: R abdomenL Stae: N/AL Sour.e: -ea#in b#i%terL Dire.tion%: C#ean%e 9it- 9ound .#ean%er4 rin%e 9it- norma# %a#ine4 .o'er 9it- me(i#e border+ C-ane e'ery ot-er day and (rn+ 0700 E'ery ot-er Day Drain% e%/No4 ;y(e8: N/A+)a%t B: 02/01/17 t-er ;ube%: N/A+ ASSESSMENTS(Include Subjectie ! Objectie #t#$ nteumentary:5ead and Ne.$:Ear/No%e/;-roat:;-ora/)un%:Cardia.:u%.u#o%$e#eta#:Genitourinary:Ga%trointe%tina#:  Neuro#oi.a#:t-er n.#ude 'ita# %in%4 9ei-t8:
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