Nursing Case Study Pneumonia

Words: 931
Pages: 4

Madison Kauffman
NURS 437
Case Study

To begin, my patient was an eighty-six-year-old male who was admitted to Penn Highlands Dubious on February 7th, 2018 He complained of severe dyspnea and increased shortness of breath aggravated by activity. He was diagnosed with right lower lobe pneumonia and had a secondary diagnosis of an exacerbation of congestive heart failure. Pneumonia can be defined as “an infection in the lungs involving the alveolar sacs and can be caused by microbes, including bacteria, viruses, or fungi” (American Thoracic Society, 2010). Pneumonia is caused when microbes enter the respiratory tract via the nose or mouth infecting the alveolar sacs in the lungs. Streptococcus pneuomoniae and Hemophilus influenzea are the
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As well the patient was pleasant to interact with and appropriately groomed. His skin was warm to touch with no skin break down present. He had bruising bilaterally in his arms. Lung sounds were diminished bilaterally and a dry, nonproductive cough was present. He became extremely short of breath when rising to go to the restroom. Pupils were equal, round, and reactive to light. His sensory and motor function were within normal limits. The patient complained of difficulty swallowing. As a result, a speech consult was order to evaluate and ensure risk of aspiration was decreased. Apical pulse was 84 and both radial and pedal pulses were +2 bilaterally. +1 Edema was present in the lower extremities, consistent with findings of individuals with heart failure. Atrial fibrillation was noted on the heart monitor and was consistent with the patient’s health history. The patient’s abdomen was soft and nondistended. active bowel sounds were noted in all four quadrants. The patient complained of pain rated as a 7 out of 10 in his left arm and noted that he had previously had a torn rotator cuff. He described this pain as a constant ache that worsened with movement. In summary, the patient’s main concerns were shortness of breath and difficulty