My Clinical Experience

An instance, in which I used the nursing process, stood as my clinical experience of caring for a 72-year-old female diagnosed with bacterial pneumonia. This patient regularly acquired pneumonia, and with her body becoming more frail and susceptible to disease, she found herself in the hospital. Upon entering the patient’s room, I encountered an older woman slumping in her bed, looking restless, and using her accessory muscles to try to get appropriate respirations. Recognizing that the patient was experiencing respiratory complications, associated with bacterial pneumonia, I began a focused assessment on the pulmonary system, while noting both subjective and objective patient data. Through speaking with the patient, she expresses that she
The patient’s oxygen status hovered at 88% on room air, remaining evident that interventions needed to occur. My immediate interventions stood as raising the head of the patient’s bed to semi-fowlers and putting her on 2L of oxygen via a nasal cannula. Throughout my assessment and care for the patient, I ensured to monitor the patient mental status, as an alteration in her level of consciousness would lead me to believe that her status was altering. Aware that pharmacological agents would assist in restoring the patient’s health, I reviewed the physician’s orders and the patient’s MAR. Following orders, I administered antibiotics, pain/fever reducing medications, and closely monitored the patient’s fluid hydration. To determine the effectiveness of my interventions, I continued to monitor vital signs, I &O, subjective data, and pulmonary status. To minimize the risk of over exertion, and increased SOB, I recommended that the patient remain in bed, and call for assistance when needing to use the restroom. With this recommendation, I remained able to ensure that my patient did not fall during ambulation or overexert
I acquired assessment data, determined interventions to implement, and reflected on the effectiveness of my care. As a result of this experience with clinical judgment, I expect to be able to accurately recognize the signs and symptoms of pneumonia, appropriate nursing interventions to implement, and realistic patient outcomes for my shift. Aware of the underuse of vaccination, I would like to enhance patient education on these vaccination as options to assist in the prevention of influenza and pneumonia, as this age remains highly susceptible to disease. In general, this experience taught me the importance of implementing both pharmacological and nonpharmacological measures into patient care. As a nurse, it remains easy to demonstrate our skills, but we cannot forget the value of human connection and comfort measures. Nursing is not purely focused on curing, but rather, an equal balance of curing and caring for