Dahuili Wang is a 90-year-old female who is admitted for bacterial pneumonia. Her main complaints include a productive cough and weakness that have been bothering the patient during the last week. At the moment of presentation, other critical signs are adventitious breath sounds, fever, hypoxia, shortness of breath, and weakness. The elderly respond to infection with low sensitivity due to hypoxia and poorly defined alterations in the immune system. In addition, people’s age is a risk factor for such diseases as pneumonia, and monitoring of their clinical stability is required. Mrs. Wang has already been waiting for some time to receive treatment, and there is a chance that her signs and conditions have worsened. Therefore, immediate priority of care is expected to treat her pneumonia and use intensive oxygenation.
Action
A nursing action plan consists of several stages, namely examination, diagnosis, and interventions. The assessment of the patient’s functioning and history proves the necessity of optimizing oxygenation. The physical examination aims at identifying the level of tissue oxygenation and the evaluation of the cardiopulmonary system work (McCalley, 2019). Diagnostic tests, such as X-ray and arterial blood gas test, can show if there is some deviation from the norm. Regarding the offered subjective and objective data, nursing diagnoses for the patient with bacterial pneumonia are impaired gas exchange, risk for infection, and risk for impaired skin integrity. An individualized care plan has to be developed for each nursing diagnosis to predict the disease-related complications and achieve the desired goals and improvements.
Impaired gas exchange is related to retained secretions and inflammatory processes in the lungs. Hypoxia, shortness of breath, and restlessness are the characteristics of this condition. The application of nursing care will help achieve such outcomes as improved ventilation and oxygenation of tissues and optimal gas exchange. One of the obligatory interventions for this case is the assessment of respirations and vital signs. A nurse has to note the quality of breathing and promote health for adequate oxygenation. This step allows manifesting respiratory distress in the patient and evaluating the degree of lung involvement. The use of accessory muscles can increase lung volume during the process of inspiration, but their prolonged assessment of respirations usage may result in fatigue. The choice of the position that is assumed for easy breathing is integral. If the patient prefers the tripod position, it has to be considered as a sign of dyspnea and the importance of assessing her for respiratory distress immediately. The nurse should also evaluate vital signs (body temperature, blood pressure, respiration rate, and pulse rate) to recognize the impact of fever and the effectiveness of medications on the patient.
Another nursing intervention focuses on the reduction of the risk for infection. In some cases, an infection may be prevented, but if it is impossible, nurses have to prevent its spread and offer recommendations. Mrs. Wang did not want to come to the hospital once she felt discomfort, which could tell about her altered mentation or poor awareness of the situation. Therefore, the hand hygiene intervention seems to be appropriate for this case to reduce the transmission of microorganisms between patients, the staff, and hospital visitors (McCalley, 2019). Every procedure that requires direct or indirect contact with the patient is a threat to the nurse and the patient. Therefore, such simple steps as washing hands between procedures can minimize unnecessary bacteria exchange. This nursing obligation cannot be ignored because the five moments for hand hygiene with antiseptics lessen the growth of infections that provoke new diseases or worsen the current patient’s condition. Soap, alcohol-based hand rub, and protective means (gloves and masks) are usually enough to complete this task and create safe conditions for Mrs. Wang and her care team.
A final relevant intervention is developed to deal with impaired skin integrity and assess the overall condition of the skin. Nurses are responsible for sharing their experience and knowledge about the patient because skin assessment is not a single activity but a regular routine that has to be taken. The age of the patient (90 years) is a critical factor for this intervention because any change is evidence that treatment does not go well or the signed medications do not work effectively. Wound care management depends on how the assessment is organized and maintained during the whole care process. This baseline data is necessary to compare the initial skin condition with the normal and changed results. For example, normal skin should be dry, free from impairment, and warm. The older patient is at risk of common impairment because her skin is not as elastic or does not have enough moisture. Therefore, the observation of Mrs. Wang’s skin and mucous membranes and the encouragement of pressure-relieving devices (good-quality mattress) become an obligatory assessment activity to predict negative skin changes, avoid unnecessary movement, and promote comfort.
Response
As soon as the nurse implements each intervention, it is important to evaluate the effectiveness of the chosen activities and predict the response of the patient. For example, the assessment of respirations and vital signs is based on regular cooperation between the patient and the nurse. This period can be used not only for observations but also for communication. It is expected that the patient responds to the nurse’s questions and reports on changes in her health. Mrs. Wang should be eager to answer the questions and share her feelings about the presented care and medications. If she observes some unpleasant sensations, she needs to report them immediately. However, every assessment and respiration technique is not associated with continuous discomfort or breathing difficulties.
Hand hygiene is one of the simplest but most provocative interventions in this case. On the one hand, most people are aware that following hygiene rules is necessary. They try to wash every part of the body and believe that it protects them against external harm. On the other hand, sometimes, it is easy to forget about this procedure or do it wrongly or not effectively. In this case, the patient or the nurse thinks that contamination is avoided, making themselves vulnerable to new infections. Therefore, the expected response to this intervention is using the necessary protective means like soap or alcoholic substances to clean hands and avoid the spread of infection.
Finally, the expected response to skin assessment and the use of pressure-relieving devices is the improvement of the condition of Mrs. Wang’s skin. Such outcomes are related to the quality of the chosen mattress (foam) and the possibility to control pressure and trap the necessary amount of moisture. The patient feels comfortable, and the nurse does not spend much time changing her position. The evaluation of the skin, as well as the assessment of vital signs and respirations, is characterized by improved nurse-patient cooperation and gathering personal data. Mrs. Wang would have dry skin that is protected against outside irritants, and the nurse would concentrate on pneumonia-related treatment without complications.
Reference
McCalley, E. H. (2019). Cardiopulmonary functioning and oxygenation. In P. A Potter, A. G. Perry, P. A. Stockert, & A. M. Halls (Eds.), Canadian fundamentals of nursing (6th ed., pp. 953-1014). Mosby.