NUR 213
Gina Perry, SN2
Central Maine Community College
Abstract
This paper illustrates how the student nurse cared for a patient with pneumonia. The student nurse was assigned a patient on a medical surgical unit during clinical rotation. During this time, the student nurse observed and interacted with the patient, conducted a full head to toe assessment as well as routine scheduled assessments, administered medications, and created a plan of care. A brief description of pneumonia is included along with the disease progression. Data collected from the patient, the patient’s chart and the interaction between the patient and the student nurse is also identified to provide the reader with the patient’s background and present condition. The nursing process was used to asses this data and identify 3 nursing diagnoses along with nursing care plans for each diagnosis. Interventions were implemented to meet short term and long term goals with positive outcomes in spite of the restricted time frame.
Introduction
Pneumonia is an acute respiratory infection that affects the lungs. The lungs are made up of small sacs called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing painful and limits oxygen intake. According to the Centers for Disease Control, pneumonia strikes over 4 million Americans each year and is the fifth leading cause of death in people age 65 and older. There are several different causes of pneumonia which include bacteria, viruses, mycoplasma, fungi, parasites, and chemicals and is classified as either community acquired or hospital acquired pneumonia. It’s important to determine the classification of pneumonia because of the differences in the likely causative organisms and their corresponding treatment. Community acquired pneumonia (CAP) involves onset in the community or during the first 2 days of
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