Developing Critical Thinking Through

Understanding Pathophysiology
Primary problem (medical diagnosis) of patient: Pneumonia

1. Define and describe in your OWN WORDS, the pathophysiology of the primary problem of your patient:

Pneumonia is an infection of the lungs that causes inflammation and fluid secretions to build up. This accumulation of
fluids and inflammation prevents the alveoli from participating in the exchange of gases within the lungs.

2. How would you explain and teach your patient about the pathophysiology of this medical problem using non-
medical terminology?

There is an infection in your lungs caused by bacteria. The infection has caused fluid to build up making it difficult for
you to breathe effectively. The antibiotics that the doctor has ordered for you should have you feeling better soon.

3. What body system(s) are directly impacted by this disease and how are those systems affected?
BODY SYSTEM(S): HOW BODY SYSTEM IS AFFECTED(S):
Lungs Ineffective gas exchange due to inflammation and the build up of secretions in the
lungs inhibiting the alveoli from exchanging oxygen and carbon dioxide.

4. PRIORITY nursing assessments with this disease? (refer to body system that is most affected). What assessment
findings may be abnormal as a result of this illness?
PRIORITY ASSESSMENTS: EXPECTED ABNORMAL ASSESSMENTS:
Assess respiratory system, Ineffective gas exchange due to inflammation and the build up of secretions in the
vitals including temperature, lungs inhibiting the alveoli from exchanging oxygen and carbon dioxide.
assess pain level.

5. What lab tests are altered by this problem? How are those lab tests affected? Does the altered lab test affect any
physical assessment findings?
ABNL. LAB TESTS: HOW LAB TESTS AFFECTED: DOES IT IMPACT ASSESSMENTS?
WBC An elevated WBC count may indicate infection. Monitor for more s/s of infection.
ABG An elevated pH, decreased pco2, and po2 are Monitor ABGs closely for changes that
X-ray indicative of respiratory alkalosis. may lead to complications.
X-rays can show areas of inflammation and fluid Monitor lungs for adventitious breath
build up within the lungs. sounds, depth, and airway patency.

6. What medications are most commonly used to manage this problem?

MEDICATIONS: MECHANISM OF ACTION (OWN WORDS):
Nebulizer treatments and Bronchodilators to open restricted airways in combination with corticosteroids to
metered dosed inhalers combat inflammation in lung to help to patient breathe more effectively

Antibiotics To combat the infection

Copyright © 2018 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.

Problem # 1 _Impaired gas exchange

Assessment Subjective Data: Patient states “I can’t seem to catch my breath.”

Abnormal
Findings Objective Data: Tachypnea, shallow breathing, breathlessness, and tachycardia upon conversation with patient. O2 saturatio
at 95% on 4L of O2

Formulate Nursing Diagnosis (actual or risk for)

Diagnosis
Impaired gas exchange R/T inflammation and excess fluid in the lungs.
Nursing
Diagnosis
formed from
NANDA
category R/T
S/O data

Plan Goal: The patient will have improved gas exchange

Goal from
patient’s Outcomes: As evidenced by absence of dyspnea and respiration rates within normal range by 8/30/23
viewpoint.
Indicate
measurable
outcomes and
include time
frame.

Interventions: Rationale:
Interventions 1. Assess the depth and rate of respiration. 1. When the lungs are
(6) inflammed and have accru
2. Elevate the head of bed. excess fluids the patient
Important: can’t effectively exchange
Begin with 3. Assist the patient in deep breathing and coughing exercises. O2 and CO2.
action verb; 2. This position can aid the
indicate type, 4. Encourage the patient to increase their fluid intake, especially warm liquids. lungs by allowing for
frequency, increased expasion which
amount where 5. Administer bronchodilators as ordered. allows more air to enter th
appropriate; lungs.
State scientific 6. Auscultate lungs for adventitious breath sounds and air flow throughout the 3. Deep breathing and
rationale/ lungs. coughing can help to expe
psychological excess sectretions that hav
principle for been building up in the
each lungs.
intervention. 4. Hyperventillation can caus
an increase in insensible
fluid loss. Warm liquids in
particular are helpful in
moving out excess lung
secretions.
5. Bronchodilators can help
open up restricted airways
allowing for more air to
enter the lungs.
6. Adventitious breath sound
like wheezing, crackles, an
rhonchi occur often in
patients with pneumonia a
indicate that there is
inflammation and or
secretions that are building
up in the lungs. There may
also be a decrease in airflo
in these areas.

Evaluation Goal has been: partially met on 8/30/23

Have the Provide evidence: respirations are between 17 and 22 but diminished. Lungs are free
goals/outcomes from adventitious sounds. Patient remains short of breath with conversation.
been met?

Provide
evidence.

Problem # 2 Activity intolerance

Assessment Subjective Data: Patient states “I get so short of breath that I can’t even get to the bathroom, so they
gave me a commode.”
Abnormal
Findings
Objective Data: Shortness of breath with casual conversation; severe dyspnea with physical activities;
O2 saturation drops, tachypnea, and tachycardia with activity.

Formulate Nursing Diagnosis (actual or risk for)

Diagnosis Activity intolerance R/T inflammation and excess fluid in the lungs.

Nursing
Diagnosis
formed from
NANDA
category R/T
S/O data
Plan Goal: The patient will improve tolerance to activities of daily living by the end of this hospital stay

Goal from
patient’s Outcomes: As evidenced by the patient’s ability to walk 20 feet to the bathroom without severe
viewpoint. dyspnea.
Indicate
measurable
outcomes and
include time
frame.

Interventions: Rationale:
Interventions 1. Evaluate the patient’s response to activity. 1. Establi
(6) shes a
2. Assist the patient with ADLs as required, while allowing for increased baselin
Important: independence as the patient improves. e for
Begin with the
action verb; 3. Monitor the patient’s response to ordered oxygen supplementation. patient
indicate type, ’s
frequency, 4. Teach the patient the importance of rest. toleran
amount where ce for
appropriate; 5. Teach and encourage isometric exercises while the patient is in bed as activiti
State scientific tolerated. es.
rationale/ 2. Allows
psychological 6. Teach and encourage active range of motion exercises as tolerated. the
principle for patient
each to rest
intervention. while
also
allowi
ng the
patient
to
increas
e self
suffici
ency to
avoid
depend
ance
on
caregiv
ers.
3. It is
impera
tive
that
the
patient
’s
oxygen
saturati
on is
adequa
te for
the
body’s
 require
ments,
especia
lly
while
trying
to do
activiti
es.
4. Rest
can
decrea
se the
body’s
metabo
lic
require
ments
and
allow
for
more
engery
to be
utilize
d for
healing
.
5. Increas
ed
move
ment
while
the
patient
is
mainly
in bed
can
help to
preven
t DVT
and
increas
e their
toleran
ce to
activit
y.
6. Active
ROM
exercis
es will
help to
gradua
lly
increas
e the
patient
’s
 toleran
ce to
activit
y and
helps
to
preven
t
decond
itionin
g
while
the
patient
remain
s in
bed for
long
periods
of
time.
Also
helps
reduce
the
risk of
DVT.

Evaluation Goal has been: unable to evaluate if goal has been reached.

Have the Provide evidence: Patient working towards improving activity tolerance while still
goals/outcomes admitted.
been met?

Provide
evidence.

Problem # 3 Risk for falls

Assessment Subjective Data: Patient states “I get dizzy when I get out of bed.”

Abnormal
Findings Objective Data: Morse fall risk score of 35 (moderate); impaired gas exchange; dizziness upon activity;
shortness of breath with conversation; respirations 17 per minute increase to 24 per minute when trying
to speak

Formulate Nursing Diagnosis (actual or risk for)

Diagnosis
At risk for fall R/T dizziness upon exertion and talking
Nursing
Diagnosis
formed from
NANDA
category R/T
S/O data

Plan Goal: The patient will not sustain injury from a fall during this hospital stay

Goal from
patient’s Outcomes: As evidenced by the patient will remain free of injuries such as ecchymosis, lacerations, skin
viewpoint. tears, and or fractures.
Indicate
measurable
outcomes and
include time
frame.
Interventions: Rationale:
Interventions 1. Maintain bed in its lowest position. 1. If the
(6) patient
2. Ensure the call button and regularly used items are within the patient’s reach. were to fall
Important: out of bed
Begin with 3. Provide signage outside of the patient’s room to indicate that the patient is at the distance
action verb; risk of falls. from the
indicate type, bed to the
frequency, 4. Maintain a clear and uncluttered floor in the patient’s room. floor is
amount where reduced
appropriate; 5. Provide adequate lighting in the patient’s room. thus
State scientific reducing
rationale/ 6. Provide and encourage the use of non-skid socks when ambulating. the severity
psychological of potential
principle for injuries.
each 2. The patient
intervention. is less
likely to
get out of
bed if they
can reach
for the
items they
need (like
water or a
tissue) or
simply call
for
assitance
using the
call bell.
3. This helps
to remind
healthcare
workers
that the
patient is at
risk for
falls and
the need to
implement
fall risk
protocols.
4. A clear
unobstructe
d room can
 prevent a
patient
from
tripping
and
sustaining a
fall.
5. A well lit
room can
help a
patient see
where
they’re
going,
especially
in an
unfamiliar
environme
nt.
6. The use of
non-skid
socks while
ambultaing
can help
prevent the
patient
from
slipping
and falling.

Evaluation Goal has been: Partially met.

Have the
goals/outcomes Provide evidence: Patient has not sustained a fall as of 8/30/23. There are
been met? preventions in place such as bed in lowest position, signage to indicate she is a fall
risk, her call bell and bedside table are within reach. Unable to fully evaluate if patient
Provide has fully met this goal.
evidence.

Patient Medication Profile

Patient # ___S._____________ Age __59_________ Admitting Diagnosis _Pneumonia_______

Comorbidities _COPD______________________________________________________________

History __COPD___________________________________________________________________
 Medication:
Drug Reason Required
Dosage Side Effects
Category Prescribed Assessments
Frequency
DuoNeb Short acting Dilates Assess lung Tachycardia, hypotension,
(Ipratropium / muscarinic bronchioles sounds, BP, palpitations, nervousness,
albuterol) antagonist and and reduces pulse before hypertension (albuterol),
2.5/3mL nebulizer short acting inflammation and after tremor, headache
q6hrs beta agonist administration
Aspirin Antiplatelet Decreases the Monitor for GI bleed,
81mg PO Decreases risk of MI. S/S of DRESS, dyspepsia, epigastric
Q 24hrs platelet (This pt had an assess for pain, distress, nausea, anemia
aggregation increased fever, monitor
troponin hepatic
levels) function
Symbicort Corticosteroid Dilates Assess lung Arrhythmias,
(Budesonide / and long- bronchioles sounds, BP, hypertension, tachycardia,
formoterol) acting inhaled and reduces pulse before oropharyngeal candidiasis,
80 mg/4.5 mcg bronchodilator inflammation and after hyperglycemia,
2 puffs metered administration hypokalemia,
dosed inhaler. bronchospasm.
BID
Ceftriaxone 3rd generation Bactericidal, Assess for diarrhea, rash, urticaria,
1 G IV push cephalosporin treats bacterialallergy to pain at IM site, phlebitis at
Q 24hrs infection penicillin or IV site, hypersensitivity
cephalosporins, reactions including
assess the anaphylaxis,
infection, be superinfections
sure a C&S
was done,
monitor bowel
function,
monitor for
foul smelling
diarrhea (C.
diff)
Enoxaparin Anticoagulant Prophylaxis for Assess for S/S Hyperkalemia, bleeding,
40 mg Low DVT of bleeding, anemia,
Sub Q molecular prevention (decrease in thrombocytopenia,
q 24hrs weight while on bed hematocrit, erythema at injection site,
heparin rest decrease in BP, hematoma, irritation, pain,
guaiac, other headache
occult
bleeding),
monitor CBC
and platelet
count (HIT)

Methylprednisolone Corticosteroid Reduces Monitor for s/s Hypertension, acne,

40 mg inflammation of occult
IV injection bleeding, fluid slower wound healing,
q 8hrs retention, ecchymoses, adrenal
 edema, suppression,
electrolyte
levels, glucose hyperglycemia,
levels, s/s of hypokalemia,
infection,
hypokalemic alkalosis, GI
bleed, peptic ulceration,
anorexia, nausea,
thromboembolism,
osteoporosis, personality
changes, restlessness,
cushingoid appearance
(moon face, buffalo hump)
Pantoprazole Proton pump To reduce the Assess for Hyperglycemia, C. diff,
40 mg inhibitor risk of abdominal bone fracture, B12
1 tab EC reduces the ulceration pain, frank or deficiency, abdominal
Q 24hrs amount of while taking occult blood in pain, diarrhea,
acid produced corticosteroids stool, and hypomagnesemia
in the stomach emesis,
monitor for
foul smelling
diarrhea