Vitamin D Deficiency N/A

Contributing factors involved in this

BSMCON NUR 3111P hospitalization such as lifestyle, PMH, FH, 1
etc N/A
Family HX- maternal grandfather: pneumonia Medications for this
Vitamin D helps to maintain
50 yo condition (name, route,
Medications for this the balance of Calcium PMH-to Vitamin D deficiency, hypertension, dose, action)
condition (name, route, help bone formationhyperlipidemia,
and depression (chronic), ADD N/A
dose, action) calcium absorption. Vitamin
Risk Factors- recent hospitalization,
Cholecalciferol (vitamin D controls T cells thatweakened
serve or suppressed immune system
D3) tablet 2,000 units as the bodys killer cells to (SM 57 yo F)
fight off infection. Therefore, Medications for this condition (name, route, dose,
orally daily; Health Care action)
less T cells were protecting
supplements the body the immune system and Acquired 0.9% Sodium Chloride Infusion 100 mL/hr IV
with Vitamin D continuously; replenishes the body of fluid and
making the body more Pneumonia electrolytes
susceptible to disease.
Pneumococcal 23 valent (pneumovax 23) injection
0.5 mL intramuscular prior to DX; vaccination- an
Priority Nursing Diagnosis (3 parts Normally, pulmonary defense mechanisms (immune injection of a small dose of the bacteria or the protein
Infection R/T invading bacterial or viral receptors, cough reflex, sneezing, mucociliary contained in the bacteria causing your body to
organisms AEB fever, positive sputum culture, clearance) protect individuals from pneumonia.
dyspnea, and cough with sputum. Community acquired pneumonia occurs when develop immunity to the disease.
Measurable outcome w/ timeframe: defense mechanisms are compromised/are commonly Doxycycline (vibramycin) 100 mg PO q12 hrs;
Patient experiences improvement in infection bacterial in origin. After microbial agents enter the inhibits protein synthesis- stops or slows the growth
AEB a body temperature between 97 to 99 lung, they multiply and trigger pulmonary or proliferation of cells by disrupting the processes
degrees Fahrenheit by 1400 on 9/2/15. inflammation. Alveolar air spaces fill with an that lead directly to the generation of new proteins.
Nursing interventions you used with rationales: exudative fluid, and inflammatory cells invade the Acetaminophen (Tylenol) tablet 650 mg PO q 4 hrs
1) Assess the patients temperature, closely alveolar septa. Acute bacterial pneumonia may be
monitoring for fluctuations: Fever suggests associated with significant mismatching and PRN; inhibits the pain receptors.
infection. Continued fever may be caused by a hypoxemia because inflammatory exudate collects in
drug allergy, drug-resistant bacteria, the alveolar spaces. Alveolar exudate tends to
superinfection, or inadequate lung drainage. consolidate and becomes difficult to expectorate.
Recent laboratory/diagnostic tests results with significance
2) Obtain fresh sputum for a Gram stain and for a Viral pneumonia does not produce exudate fluids. (i.e. why are they high/low?)
culture and sensitivity, as prescribed, Assess for Chest x-ray: Provides an image to identify structural
drug resistance: This testing determines the distribution, which may reveal abscesses and infiltration.
correct antibiotic coverage for the patient, A blood Anticipated patient teaching required Indication: pneumonia increasing size of a consolidation in
culture obtained before the initial antibiotic is Ways to prevent infection: the right upper lobe. Slight improvement of the left lung
given is an indicator or benchmark used to Vaccines; for the flu and pneumonia. base.
measure the quality of care in hospitals. In the The importance of hand washing. Pulse Oximetry: 91% The airways may be filled with mucus
outpatient setting, patients will often be treated Avoid individuals who have the cold, flu, or respiratory or pus, creating impaired gas exchange
empirically. infections. Psychosocial / Spiritual issues and discharge
3) Wash hands frequently and instruct the patient Contact the doctor if you have a fever with shaking needs
and/or family to do the same: Hand washing is the chills, a cough that produces blood-tinged or rust- PT is independent. Lives with daughter and two
colored mucus from the lungs, difficult, shallow, fast grandchildren. Assess grandmothers level of
most effective method for preventing the spread
breathing with shortness of breath, or wheezing.
of infection. involvement in childcare and household
Evaluation: maintenance. Educate the PT and family about the
The outcome was met. importance of vaccination and proper hand
(Gulanick & Myers, 476-478) hygiene.
BSMCON NUR 3111P
2

Physical Assessment
This section must be completed by the stated due date/time and given to your instructor.

Document the assessment you completed.

Assessment Findings
Safety Fall risk: PT is receiving diphenhydramine (Benadryl) 50 mg injection IV 4 times
daily; assess for drowsiness. Schmid score: 1
Skin/Wounds Location of wound: posterior- sacrum/coccyx, red, open-to-air; encourage turning
q 2 hrs. Head to toe rash with itching. Skin is intact, hot and red. Diaphoresis.
Elastic turgor. Braden scale: 23.
Respiratory RR: 20 @ 0700 & 20 @ 1100, unlabored. Dyspnea upon exertion. Chest is
symmetric. Rales/ fine crackles noted bilaterally on lower bases. No wheezing. No
use of accessory muscles. Productive cough with sputum. Occasional oxygen use
when pulse oximetry is below 90%: 2L, nasal cannula. Incentive spirometry @
1030: 1250 mL.
Cardiovascular HR: 100 @ 0700 & 83 @ 1100. Rate and rhythm appropriate for age. S1 & S2
audible, no murmurs noted. Carotid, radial, dorsalis pedis, and posterior tibial + 2
bilaterally. Capillary refill: brisk. No edema or JVD.
Gastrointestinal Soft, non-tender. No masses or hernias. Last BM 9/1/15; approximately 0930. No
pain or discomfort.
Genitourinary PT is continent. Two urine occurrences @ 0830 & 1310; unmeasurable. Urine is
clear, yellow/straw, with no odor.
Neurological Alert, cooperative, appropriate affect & judgement. Mood appropriate. A&Ox4.
Speech clear. CNs intact.
Musculoskeletal Gait steady. Grips 5/5 equal bilaterally in upper and lower extremities. Dorsi/
plantar flexion equal 5/5 bilaterally.
IV Lines Peripheral IV Left Antecubital 22 G: removed 1143 by Ally, RN. Infiltration:
Drains/Equipment swelling and pallor, IV catheter was visibly dislodged from the vein.
Peripheral IV Right Antecubital 22 G: inserted 1155 by Ally, RN. IV site free of
redness and PT reports no pain. IV line is patent and fluids are infusing at 100
mL/hr of 0.9% Sodium Chloride.
O2: 2L, nasal cannula.

List two goals for the next practicum experience:

1. Continue to improve on concept maps and physical assessment.
2. More confidence in medication administration especially in IV routes.
 BSMCON NUR 3111P
3

Lasater Clinical Judgment Rubric Scoring Sheet

Developed by Kathie Lasater, Ed.D.; Based on Tanners Integrative Model of Clinical Judgment (2006)

Student Name: Date/Time: Clinical Site:

Clinical Judgment Components Notes

Noticing:
Focused Observation: B D A E
Recognizing Deviations from Expected Patterns:
B D A E
Information Seeking: B D A E
Interpreting:
Prioritizing Data: B D A E

Making Sense of Data: B D A E

Responding:
Calm, Confident Manner: B D A E
Clear Communication: B D A E
Well-Planned Intervention/Flexibility: B D A E

Being Skillful: B D A E

Reflecting:
Evaluation/Self-Analysis: B D A E
Commitment to Improvement: B D A E
Summary Comments: