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This Concept Map, created with IHMC CmapTools, has information related to: Pneumonia, Problem: Airway patency ND: Ineffective airway clearance Data: Abnormal lung sounds, cough, dyspnea, and infiltrates seen on chest x-ray Interventions: Assess respiratory movements and use of accessory muscles. Monitor pulse oximetry and ABGs. Use optimal positioning; encourage ambulation. Pace activities. Provide oral care. Outcomes: The patient's airway is free of secretions as evidenced by eupnea and clear lung sounds. lead to Problem: Discomfort ND: Acute pain/Discompart Data: Respiratory distress and coughing Interventions: Assess complaints of discomfrot and pain Administer analgesics as prescribed or PRN. Use additional measures, such as positional and relaxation techniques. Outcomes: The patient will verbalize relief or reduction in pain/discomfort., Problem: Pneumonia ND: Infection Data: Elevated temperature, elevated WBC, Tachycardia, chills, diffuse infiltrates on RUL Interventions: Assess vital signs , closely monitoring temprature. Monitor lung sounds, WBC, ABGs. Administer prescribed antibiotics and monitor effectiveness of the medications. Outcomes: The patient will experience improvement in infection as evidenced by normothermia, normal WBC, and no infiltrates seen on x-ray. lead to Problem: Airway patency ND: Ineffective airway clearance Data: Abnormal lung sounds, cough, dyspnea, and infiltrates seen on chest x-ray Interventions: Assess respiratory movements and use of accessory muscles. Monitor pulse oximetry and ABGs. Use optimal positioning; encourage ambulation. Pace activities. Provide oral care. Outcomes: The patient's airway is free of secretions as evidenced by eupnea and clear lung sounds., Problem: Pneumonia ND: Deficient knowledge Data: New condition and procedures Interventions: Assess potential home care needs. Teach the patient deep breathing exercises. Educate the patient and his wife about the need to complete the full course of antibiotics. Obtain immunizations against influenza and pneumococcal vaccine. Outcomes: The patient and care giver demonstrate understanding of disease process and isolation procedures. can prevent recurrent and his wife from penumonia Problem: Pneumonia ND: Infection Data: Elevated temperature, elevated WBC, Tachycardia, chills, diffuse infiltrates on RUL Interventions: Assess vital signs , closely monitoring temprature. Monitor lung sounds, WBC, ABGs. Administer prescribed antibiotics and monitor effectiveness of the medications. Outcomes: The patient will experience improvement in infection as evidenced by normothermia, normal WBC, and no infiltrates seen on x-ray., Mr. N : 72 years old living with his wife : A history of COPD and pset smoking : Complains of fever, dyspnea, cough with whitish sputum production, and chills : DX: Pneumonia : T 102, HR 124, RR 24, and BP 112/78 : WBC 19.7 : Chest x-ray: diffuse infiltrates on RUL : Lung sound: Crackles : ABGs: pH 7.32, PaCO2 47, HCO3 24, and PaO2 79 cause Problem: Discomfort ND: Acute pain/Discompart Data: Respiratory distress and coughing Interventions: Assess complaints of discomfrot and pain Administer analgesics as prescribed or PRN. Use additional measures, such as positional and relaxation techniques. Outcomes: The patient will verbalize relief or reduction in pain/discomfort., Problem: Pneumonia ND: Deficient knowledge Data: New condition and procedures Interventions: Assess potential home care needs. Teach the patient deep breathing exercises. Educate the patient and his wife about the need to complete the full course of antibiotics. Obtain immunizations against influenza and pneumococcal vaccine. Outcomes: The patient and care giver demonstrate understanding of disease process and isolation procedures. need for treatment Mr. N : 72 years old living with his wife : A history of COPD and pset smoking : Complains of fever, dyspnea, cough with whitish sputum production, and chills : DX: Pneumonia : T 102, HR 124, RR 24, and BP 112/78 : WBC 19.7 : Chest x-ray: diffuse infiltrates on RUL : Lung sound: Crackles : ABGs: pH 7.32, PaCO2 47, HCO3 24, and PaO2 79, Mr. N : 72 years old living with his wife : A history of COPD and pset smoking : Complains of fever, dyspnea, cough with whitish sputum production, and chills : DX: Pneumonia : T 102, HR 124, RR 24, and BP 112/78 : WBC 19.7 : Chest x-ray: diffuse infiltrates on RUL : Lung sound: Crackles : ABGs: pH 7.32, PaCO2 47, HCO3 24, and PaO2 79 cause Problem: Pneumonia ND: Infection Data: Elevated temperature, elevated WBC, Tachycardia, chills, diffuse infiltrates on RUL Interventions: Assess vital signs , closely monitoring temprature. Monitor lung sounds, WBC, ABGs. Administer prescribed antibiotics and monitor effectiveness of the medications. Outcomes: The patient will experience improvement in infection as evidenced by normothermia, normal WBC, and no infiltrates seen on x-ray., Problem: Pneumonia ND: Infection Data: Elevated temperature, elevated WBC, Tachycardia, chills, diffuse infiltrates on RUL Interventions: Assess vital signs , closely monitoring temprature. Monitor lung sounds, WBC, ABGs. Administer prescribed antibiotics and monitor effectiveness of the medications. Outcomes: The patient will experience improvement in infection as evidenced by normothermia, normal WBC, and no infiltrates seen on x-ray. lead to Problem: Discomfort ND: Acute pain/Discompart Data: Respiratory distress and coughing Interventions: Assess complaints of discomfrot and pain Administer analgesics as prescribed or PRN. Use additional measures, such as positional and relaxation techniques. Outcomes: The patient will verbalize relief or reduction in pain/discomfort., Problem: Airway patency ND: Ineffective airway clearance Data: Abnormal lung sounds, cough, dyspnea, and infiltrates seen on chest x-ray Interventions: Assess respiratory movements and use of accessory muscles. Monitor pulse oximetry and ABGs. Use optimal positioning; encourage ambulation. Pace activities. Provide oral care. Outcomes: The patient's airway is free of secretions as evidenced by eupnea and clear lung sounds. associated with Problem: Gas excahnge ND: Impaired gas exchange Data: Dyspnea, decreased PaO2, Increased PaCO2, Tachypnea, Tachycardia, and decreased activity tolerance. Interventions: Assess respirations and changes in orientation. Monitor ABGs and oxigen saturation. Maintain oxygen administration devide as ordered. Pace activities to the patient's tolerance. Outcomes: The patient will maintain optimal gas exchange as evidenced by eupnea, normal ABGs, and alert responsive mentation., Problem: Gas excahnge ND: Impaired gas exchange Data: Dyspnea, decreased PaO2, Increased PaCO2, Tachypnea, Tachycardia, and decreased activity tolerance. Interventions: Assess respirations and changes in orientation. Monitor ABGs and oxigen saturation. Maintain oxygen administration devide as ordered. Pace activities to the patient's tolerance. Outcomes: The patient will maintain optimal gas exchange as evidenced by eupnea, normal ABGs, and alert responsive mentation. lead to Problem: Discomfort ND: Acute pain/Discompart Data: Respiratory distress and coughing Interventions: Assess complaints of discomfrot and pain Administer analgesics as prescribed or PRN. Use additional measures, such as positional and relaxation techniques. Outcomes: The patient will verbalize relief or reduction in pain/discomfort., Mr. N : 72 years old living with his wife : A history of COPD and pset smoking : Complains of fever, dyspnea, cough with whitish sputum production, and chills : DX: Pneumonia : T 102, HR 124, RR 24, and BP 112/78 : WBC 19.7 : Chest x-ray: diffuse infiltrates on RUL : Lung sound: Crackles : ABGs: pH 7.32, PaCO2 47, HCO3 24, and PaO2 79 cause Problem: Airway patency ND: Ineffective airway clearance Data: Abnormal lung sounds, cough, dyspnea, and infiltrates seen on chest x-ray Interventions: Assess respiratory movements and use of accessory muscles. Monitor pulse oximetry and ABGs. Use optimal positioning; encourage ambulation. Pace activities. Provide oral care. Outcomes: The patient's airway is free of secretions as evidenced by eupnea and clear lung sounds., Problem: Gas excahnge ND: Impaired gas exchange Data: Dyspnea, decreased PaO2, Increased PaCO2, Tachypnea, Tachycardia, and decreased activity tolerance. Interventions: Assess respirations and changes in orientation. Monitor ABGs and oxigen saturation. Maintain oxygen administration devide as ordered. Pace activities to the patient's tolerance. Outcomes: The patient will maintain optimal gas exchange as evidenced by eupnea, normal ABGs, and alert responsive mentation. associated with Problem: Pneumonia ND: Infection Data: Elevated temperature, elevated WBC, Tachycardia, chills, diffuse infiltrates on RUL Interventions: Assess vital signs , closely monitoring temprature. Monitor lung sounds, WBC, ABGs. Administer prescribed antibiotics and monitor effectiveness of the medications. Outcomes: The patient will experience improvement in infection as evidenced by normothermia, normal WBC, and no infiltrates seen on x-ray., Aging COPD Smoking predisposing to Mr. N : 72 years old living with his wife : A history of COPD and pset smoking : Complains of fever, dyspnea, cough with whitish sputum production, and chills : DX: Pneumonia : T 102, HR 124, RR 24, and BP 112/78 : WBC 19.7 : Chest x-ray: diffuse infiltrates on RUL : Lung sound: Crackles : ABGs: pH 7.32, PaCO2 47, HCO3 24, and PaO2 79, Mr. N : 72 years old living with his wife : A history of COPD and pset smoking : Complains of fever, dyspnea, cough with whitish sputum production, and chills : DX: Pneumonia : T 102, HR 124, RR 24, and BP 112/78 : WBC 19.7 : Chest x-ray: diffuse infiltrates on RUL : Lung sound: Crackles : ABGs: pH 7.32, PaCO2 47, HCO3 24, and PaO2 79 cause Problem: Gas excahnge ND: Impaired gas exchange Data: Dyspnea, decreased PaO2, Increased PaCO2, Tachypnea, Tachycardia, and decreased activity tolerance. Interventions: Assess respirations and changes in orientation. Monitor ABGs and oxigen saturation. Maintain oxygen administration devide as ordered. Pace activities to the patient's tolerance. Outcomes: The patient will maintain optimal gas exchange as evidenced by eupnea, normal ABGs, and alert responsive mentation.