Productive coughing and difficulty breathing

Millie has been hospitalized for several days now and has developed a fever of 102 F with some productive coughing and difficulty breathing. She is also complaining of some  pleuritic chest pain when she tries to take a deep breath. Her respiratory rate has
increased to 26 breaths per minute, and her heart rate is 60, blood pressure is 98/66
mm Hg, O2 saturation is 90% on 6 L/min oxygen via nasal cannula. When the nurse
assessed Millie’s lung sounds, she heard rhonchi and scattered crackles. A chest X-ray
was obtained, and Millie is diagnosed with hospital-acquired pneumonia. A complete
blood count was drawn, and the results show that Millie’s white blood cell count is
22,000.

New orders have been obtained from the provider, and Millie is to be transferred to a
Special Care Unit (SCU) to monitor her condition more closely.

New orders include:
• Obtain sputum specimen and blood cultures.
• Oxygen at 6-8 Liters high flow nasal cannula to keep O2 sat at or above 92%
• Normal saline intravenous solution at 100 mL/hr
• Ciprofloxacin (Cipro) 400 mg intravenous mini bag every 12 hours
• Acetaminophen 650 mg oral every 6 hours prn for fever greater than 101F
• Tramadol hydrochloride 50mg (oral) every 4-6 hours PRN for pain
• Albuterol respiratory nebulizer treatments q 4 hours and prn
• Respiratory monitoring per acute protocol

Millie still has a Foley catheter in place, and her urinary tract infection has resolved, but
the provider still wants to strictly monitor her intake and output. Millie is lethargic and
appears very ill and still is not eating well or taking in oral fluids as the provider would
like. Her intake has only been 300 mL IV fluids, 50 mL oral intake plus sips, and output
of 200 mL clear yellow urine.

 

 

 

Question

 

SUBJECTIVE DATA (Assessment)
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OBJECTIVE DATA (Assessment)
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ACTUAL PATIENT PROBLEM (PES Format- PROBLEM related to ETIOLOGY as manifested by SYMPTOMS or defining characteristics)
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GOAL(S)/OUTCOME(S) (Include goals utilizing the SMART format: Specific, Measurable, Attainable, Realistic and Timely)
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IMPLEMENTATION (Nursing/Collaborative Interventions/Care Strategies
– minimum 3 per goal/outcome)
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RATIONALE FOR CARE INTERVENTIONS/STRATEGIES (Explanation of
how/why your interventions work to resolve the problem)
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EVALUATION (Assess client to determine if they met the goal(s)/outcome(s) established. Provide evidence to support your evaluation. If
goal(s)/outcome(s) were not met- what other interventions may be needed?)
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