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Patient with Pneumonia: Health Assessment Case Study

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Updated: Aug 9th, 2020

History / Subjective

The subjective diagnosis highlights that the patient has the symptoms and background of pneumonia (Jarvis 618). It was revealed previously that Helen was treated from pneumonia and hypertension, but the prescribed antibiotics did not contribute to any positive results. Speaking of her medical history, the woman has type II diabetes, hypertension, hyperlipidemia, and osteoarthritis.

The presence of these chronic diseases increases the possibilities of the development of pneumonia. To support this hypothesis, some researchers highlight that patients with diabetes II are more vulnerable to cardiovascular diseases and respiratory illnesses (Liu 268). In this case, the medical history underlines the possibility of the occurrence of pneumonia, as the woman has heart problems and diabetes, which are viewed as favorable conditions for the progress of this illness. Lastly, her family history and current lifestyle do not contribute to the development of many chronic diseases.

PE Findings / Objective

At the same time, it is essential to conduct a physical examination to determine the diagnosis and prescribe relevant medication and treatment to the patient (Jarvis 787; Forbes and Watt 413). The typical signs of pneumonia include high breath rate, pain, chills, and the absence of high fever (Boltz et al. 32). These atypical symptoms of pneumonia are often present among the adults since the changes in their bodies modify the responsiveness of the organism to the illness (Boltz et al. 33).

To support the presumptive diagnosis, the woman has increased blood pressure (162/90), insignificant fever (37.8C), and an intensified respiratory rate (28 breaths per minute). At the same time, Helen complains about the pain in the chest, and physical examination depicts bibasilar clackers, bilateral expiratory wheezes, and dullness over the right base. In turn, it was also highlighted that the bilateral anterior cervical and supraclavicular lymphadenopathy takes place. It could be said that physical examination highlights the symptoms of pneumonia, and additional laboratory testing such as erythrocyte sedimentation rate could be provided to reveal the progress of the intervention.

Assessment / Differential Diagnosis

A combination of objective and subjective examination helps understand the nature of the patient’s condition (Jarvis 618). In the first place, Helena complains about the pain in the chest, increased breathing rates, and coughing. At the same time, the presumptive diagnosis highlights the potential development of pneumonia. Meanwhile, the woman’s chronic cardiovascular disease and type II diabetes increase the possibility of the progression of this illness (Liu 268).

In turn, the changes like the symptoms due to the age, and the physical examination underlines tachypnea, bibasilar crackles, and bilateral expiratory wheezes. It could be said that all of the information depicted previously emphasizes that pneumonia is the appropriate diagnosis. Nonetheless, one has to pay high attention to type II diabetes, hypertension, hyperlipidemia, osteoarthritis, and prescribed medication while designing the nursing care plan.

Plan / Diagnostic Work-up

As for the nursing plan, in the first place, the woman has to be informed about her condition, as it will help her prepare for the required medical intervention (Bastable 25). It will assist in avoiding ethical issues. The next step is to conduct testing to identify the initial cause of pneumonia. This approach will help adjust treatment and determine whether azithromycin and hydrochlorothiazide are appropriate in this case.

CT scans would be used to add details to the diagnosis and highlight the nature of the disease (Webb, Brant, and Major 175). The respiratory treatments will continue to minimize the shortness of breath. At the same time, pain relievers (Tylenol) and cough medications will be prescribed to determine the effectiveness of interventions to the patient. The condition of the patient will be monitored regularly to see the progress of the treatment.

Works Cited

Bastable, Susan. Essentials of Patient Education. Burlington: Jones & Bartlett Learning, 2016. Print.

Boltz, Marie, Elizabeth Capezuti, Terry Fulmer, and Diane Zwicker. Evidenced-Based Geriatric Nursing Protocols for Best Practice. New York, Springer Publishing Company, LLC, 2015. Print.

Forbes, Helen, and Elizabeth Watt. Jarvis’s Physical Examination and Health Assessment. St. Louis: Elsevier, 2015. Print.

Jarvis, Caroline. Physical Examination and Health Assessment. St. Louis: Elsevier, 2016. Print.

Liu, Jian. “Impact of Diabetes Mellitus on Pneumonia Mortality in a Senior Population: Results from the NHANES III Follow-Up Study.” Journal of Geriatric Cardiology 10.3 (2013), 267-271. Print.

Webb, Richard, William Brant, and Nancy Major. Fundamentals of Body CT. Philadelphia: Elsevier, 2016. Print.

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