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Core measures of nursing care plan of pneumonia

Patient number 5964-5-2, my patient, is an elderly person of 69 years, on his arrival, I did an examination, and the patient was suffering from community-acquired pneumonia. Community-acquired pneumonia is a type of pneumonia that is developed by a patient who has no or little contact to any health facility (In Deutschman, & In Neligan, 2015). Therefore, to make the practice more evidence-based upon arrival, I drew out blood culture before administration to any form of antibiotics.

Pneumonia is an infection that normally inflames the air sacs in the lungs due to bacterial infection. It is characterized mainly by a cough with pus or phlegm and mostly attack young children and older people of 65 and above. Assertively, I conducted a fact-finding interview in my physical assessment and found out the following; the patient maintained chest pain during breathing, coughing, fever, and change in mental awareness or confusion, shaking chills and sweating.

During my physical assessment, I almost confused community-acquired pneumonia with influenza. The two respiratory diseases manifest and portray more or less similar signs and symptoms. Some of those sign and symptoms includes a cough, fever or chills, fatigue or feeling tired. The assessment was only confirmed after a blood culture was cured out with the result showing a strong blood culture.

When it comes to diagnostic test is so controversial, since the most common and most applicable diagnostic test of community-acquired pneumonia is Streptococcus pneumonia other than X-rays and laboratory test. Blood culture is the best confirmatory test of this disease, and the strongest indication of blood culture in the process denotes a severe community-acquired pneumonia or CAP and a clear indicator of those patients with inability to remove bacteria. The patients who fall in this category include those that suffer from terminal illnesses such as cancer, inactive spleen, liver disease, or complement deficiencies. Moreover, sputum specimen for culture and Gram stain may be recommended to certain patients with other kinds of pneumonia (Godshall, 2010).

A different organization such as the infectious disease society of America has unleashed comprehensive guidelines of CAP management in adults. The evidenced based outlines are very effective in shortening the time needed to switch to various activities such as switching from I.V. oral antibiotics, the length of stay as well as the time required to achieve clinical stability.

The data obtained from my patient after an examination of the Chest radiology shown that my patient was having a heart rate of 115, respiratory rate of 27. In addition, in the diagnostic process, reading from the x-ray image, I realized an increased volume of the air sacs and the lungs not centered at the hilum. Notably, the majority of pneumonia patients have a hyperdynamic respiratory response, which is featured by the low cardiac output abnormally vast difference in arteriovenous oxygen. The above diagnostics data were shown from the examination results, and these confirm the condition of my client.

Comparatively, the treatment I rendered to my patient qualify to be evidence-based practice since its core measures were in tandem with the terms of the evidence-based nursing practice. In my practice, I carried out blood culture before the first dose of antibiotic, which is a confirmatory test even for severity of the disease. The initial dose of antibiotic I administered in the first four hours of arrival were antibiotics of choice depending on the result and examination data obtained (In Goldstein, & Morrison, 2013).

In addition, during the first step of diagnosis I carried out an oxygenation assessment within the 24 hours or a day of arrival, this was to test for the abnormal arteriovenous oxygen imbalance or difference. In my few periodic checkup within the first day of arrival, I did counsel the patient on the on the implication of smoking o his health and the significance of leading a healthy life leaving a life free from drugs. Moreover, owing to the fact that my patient was aged and prone to a subsequent attack of the same disease I carried out a pneumococcal vaccination as well as influenza vaccination before his discharge using the contraindication documentation.

Collaborative interventions are very imperative in the nursing profession and very use full disease examination and treatment. Observing on body temperature, warmth, discharge since on the onset of infection, the immune system is stimulated, and many signs of infections appear. Periodic assessment and record keeping of body temperature is important because some patients do not produce enough inflammatory response (In Fleisher, 2013). In a case, where body temperature is the key determinant for treatment, the source of data for decision-making, it is advisable to use mercury or electronic thermometer to assess temperature with electronic and mercury thermometer with well-established accuracy. Moreover, is important to take note and report laboratory values and results of a different specimen such as blood, serum protein, white blood cells count, and cultures since they are essential for client’s immune function, physical examination, and health history (Melnyk, & Fineout-Overholt, 2011).

In comparison, my care plan for my patient was consistent to some of the existing Nursing care plans, which posit that upon arrival the nurse, should carry out physical assessment and interview, diagnostics and nursing interventions and yes I did meet the care plan.

In conclusion, evidence-based nursing practice is the best way to go in the nursing profession since it gives a clear outline of and timeline for good nursing care plan.

Reference list

Godshall, M. (2010). Fast facts for evidence-based practice: Implementing EBP in a nutshell. New York: Springer Pub. Co.

In Goldstein, N. E., & In Morrison, R. S. (2013). Evidence-based practice of palliative medicine. Philadelphia: Elsevier/Saunders.

Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

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Core measures of nursing care plan of pneumonia

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