Nursing Process for Pneumonia - Case Study Example

Nursing Process, Critical Thinking and Analysis: Pneumonia Introduction Nurses play an important role in the health promotion of an individualdue to their direct contact and proximity with the patients (Nettina, 2006). Their actions have an impact on the individual and affect their levels of dependence/independence and these include biological, psychological, socio-cultural, environmental and politico-economic variables (Roper et al, 2002). Nursing process is the strategy which is employed by the nurses to deliver appropriate care to the patients they take of. It is an important framework of nursing care and mainly oriented towards patient care and goals of nursing care. There are basically five stages in the nursing process (Nettina, 2006). They are assessment, diagnosis, planning, implementation and evaluation. The relationship between a nurse and a patient is of therapeutic nature and based on the provision of care, guidance and assistance of the patient (Neal, 2007). In this essay, nursing process of a patient with multiple health problems and currently admitted for pneumonia will be described. Critical thinking and analysis will be used during the nursing process because these are very essential attributes of competent nursing care (Barrett et al, 2009). Assessment Careful history of the patient was taken, including past history and drug history. This included elucidation of appropriate history pertaining to the chronic disorders and the health status of 70 year old Robbins, a widower, who lives in the rural Victoria coast with his daughter and is a known patient of advanced prostate cancer on hormone therapy. He has bone metastases and hence is on biphonates. He, however is an active person. His current problems are incontinence of urine, dementia, ischemic heart disease and breathing difficulty due to pulmonary fibrosis. He is now admitted for evaluation and management of pneumonia. The presenting complaints with which Robbins was admitted were fever, cough and difficulty in breathing. Cough was productive with yellowish sputum. fever was high and intermittent. On examination, Robbins was febrile (102 degree F) and toxic. He had tachycardia (20 per minute), tachypnoea (28 per minute) and hypertension (140/90mmHg). Saturations were 88 percent in room air. He was however, consious, alert and oriented. Chest examination revealed crepitations mainly in the right lower lobe with a few rhonchi and crepitations dispersed all over the lung. Other systems examination was unremarkable. The psychosocial response to the disease was reviewed along with resources available and the social support network present. Robbins did not have enough social support. His only support was his daughter. Diagnosis Clinically, a diagnosis of right lower lobe pneumonia was made and a chest X-ray was taken in anterio-posterior view. It revealed consolidation of right lower lobe within a scenario of pulmonary fibrosis. Other tests done were complete blood picture, blood culture and arterial blood gas analysis. Inflammation of the alveolar tissue of the lungs is known as pneumonia. There are several causes to pneumonia, of which the most common is bacteria. Pneumonia occurs due to presence of virulence factors and due to decreased immunity secondary to chronic disease as in Alison. Pneumonia causes accumulation of fluid and inflammatory mediators resulting in ventilation-perfusion defect, impaired gas exchange and inadequate oxygenation of tissues resulting in increased respiratory rate and increased work of breathing. (Stephen, 2010). The nursing diagnoses for Robbins were: 1. Impaired gas exchange secondary to impaired ventilation-perfusion as a result of infection and inflammation of the lungs. Short term goal: Restoration of normal respiratory rate, control of temperature and infection and improvement in oxygen saturations. Long term goal: Prevention of repeat episoses and prevention of accumulation of fluid. 2. Ineffective airway clearance secondary to improper drainage of tracheo-bronchial secretions. Short-term goal: Restoration of normal respiratory rate and improvement in oxygen saturation Long-term goal: Prevention of accumulation of fluid in the lungs Expected outcomes 1. Decrease in fever and respiratory rate 2. Decrease in oxygen requirement and normalization of saturations Interventions :Planning and implementation 1. Improving gas exchange The patient was admitted to intensive care unit where he was closely monitored. Vitals signs were checked hourly to evaluate response to treatment. He was started on oxygen through mask. Initially he was started on 5 liters per minute of oxygen. The patient was observed for cyanosis, dyspnoea, hypoxia and confusion which indicate worsening of the clinical condition of the patient. In view of chronic pulmonary fibrosis, oxygen was provided only as much as needed and every effort was made to taper the oxygen delivered based on hypoxaemia. Arterial blood gas analysis revealed mild carbondioxide retention because of his chronic lung disease. the patient was positioned in the upright position in order to allow maximum lung expansion and improved aeration (Nettina, 2006). 2. Enhancing clearance of the airways Early morning fresh sample of sputum was collected which was sent for gram stain and culture. The patient was encouraged to cough because accumulation of secretions in the airways further disrupts proper ventilation and perfusion. Suctioning was done as necessary. The patient was started on intravenous fluids and encouraged to take as much fluid as possible in order to cause thinning of mucus secretions and facilitate expectoration. The oxygen provided was humidified to loosen secretions and imporve ventilation. Chest physiotherapy in the form of chest percussion and postural drainage was applied to drain mucus. The patient was mobilized frequently to improve the clearance of secretions. The patient was started on antibiotics to treat infection. Initially empirical treatment was initiated which was later changed based on the culture and sensitivity reports. Since more often than not, bacteria is the cause and broad spectrum antibiotics like cephalosporins or augmentin were initiated intravenously even before the culture reports came. Once the culture reports were available antibiotics were changed accordingly. To control fever and discomfort paracetamol was given round the clock. Holistic care Robbins received person-centered care and the care and treatment took into account his needs and preferences. He was provided opportunity to make informed decisions about his treatment in partnership with his physicians and other health professionals. It is very essential to establish good communication between health professionals and Robbins and the communication must be supported by information that is evidence based and tailored to his needs. The treatment provided was in accordance with his culture and spirituality (Nettina, 2006). His daughter and other dear ones were also be involved in the decision-making. His daughter was provided appropriate support as needed. Evaluation The patients vital signs were monitored every hour to evaluate response to treatment. The patient was on continuous oximetry. Lungs and heart were auscultated every four hours. The patient was assessed for alterations in mental status, unusual behaviour, stupor and heart failure. Patient education and health maintenance The patient was advised that weakness, depression and fatigue could be prolonged after pneumonia. After subsidence of fever, chair rest was advised to the patient. The activities of the patient were gradually increased to bring the energy levels back to pre-illness stage. Breathing exercises were advised to clear the lungs of secretions and promote full expansion of the lungs. The patient was advised to repeat chest X-ray after 4-6 weeks to evaluate for clearance of lungs and evidence of lung tumor or metastases. He was also advised to quit smoking. Adequate rest and nutritious diet was advised to prevent recurrent infections. Patient was also advised to avoid sudden extremes of temperature, fatigue and excessive alcohol intake. He was advised yearly immunisation for streptococcus pneumonia and influenza. Frequent hand washing and avoidance of meeting people with upper respiratory tract infections were recommended (Nettina, 2006). Critical thinking During the nursing care of Mr. Robbins, critical thinking was used during the nursing process. Critical thinking may be defined as "the disciplined, intellectual process of applying skillful reasoning as a guide to belief or action" (Paul, cited in Heaslip, 2008). It is "the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care" (Heaslip, 2008). Administration of oxygen was done with caution in view of chronic lung disease in the background of acute scenario. Chronic lung disease causes carbon-di-oxide retention and administration of excess oxygen may remove the ventilatory drive (Nettina, 2006). Antibiotics were also administered based on the chronic nature of the disease in the patient. Critical thinking involves "adherence to intellectual standards, proficiency in using reasoning, a commitment to develop and maintain intellectual traits of the mind and habits of thought and the competent use of thinking skills and abilities for sound clinical judgements and safe decision-making" (Heaslip, 2008). Conclusion Elderly patient Robbins was provided nursing care using the framework of nursing process. Critical thinking and analysis was applied during provision of nursing care as it allows competent nursing care. This case study implies that through application of frame work of nursing and by using critical thinking and analysis competent nursing care can be provided. This critical thinking is a very important aspect of nursing care. References Barrett, D., Wilson, B., Woollands, A. (2009). Care Planning: a guide for nurses. Harlow: Pearson Education Heaslip, P. (2008). Critical Thinking: To Think Like A Nurse. In: The Critical Thinking Community. Retrieved on 23rd October, 2010 from http://www.criticalthinking.org/resources/HE/ctandnursing.cfm Nettina, S.M. (2006). Manual of Nursing Practice. (8th ed.). New York: Lippincott Williams & Wilkins. Neal, K. (2007). Nurse-Patient relationships. Retrieved on 23rd October, 2010 from http://www.nursing-practice.co.uk/docs/newCh5.pdf Roper, N., Logan, W. & Tierney, A. (1996). The Elements of Nursing Model for nursing based on a Model for Living. (4th ed.). Edinburgh: Churchill Livingstone. Stephen, J.M. (2010). Bacterial Pneumonia. Emedicine from WebMD. Retrieved on 23rd October, 2010 from http://emedicine.medscape.com/article/807707-overview Read More