careplan2 - 12/03, 11/05 STUDENT NAME Christina Liebdzinski...

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12/03, 11/05 UPMC – SHADYSIDE - SCHOOL OF NURSING STUDENT NAME Christina Liebdzinski NURSING PRACTICE STRATEGIES WITH ADULTS CLIENT DATA SHEET – N201/202/203 DATES OF CARE: 5/15/07-5/17/07 CLIENT PROFILE INITIALS: KF RM:657 W NUTRITION: Cachectic AGE: 56 RELIGION: M HT:5’0 WT:105 OCCUPATION: retired HOSPITAL DIET: regular # 8 CULTURAL BACKGROUND: Caucasian FALL RISK SCORE: 14 BRADEN SCORE: 18 CODE STATUS/PALLIATIVE CARE: Full Resuscitation ALLERGIES/REACTION (to medication, food, environment and home): NKA MEDICAL DIAGNOSIS THIS ADMISSION : Pneumonia with MRSA CURRENT SURGERY: DATE OF SURGERY: Pathosynthesis (discussion and comparison of client to pathophysiology, include appropriate lab values, diagnostic tests and clinical manifestations). *If appropriate include gerontological considerations. Include reference or source. Pneumonia is an acute infection of the lung parenchyma that commonly impairs gas exchange. May be viral, bacterial, fungal, or protozoal in origin. Pneumonia is caused by exposure to pathogens, which get into the respiratory tract and form infections. Infection triggers alveolar inflammation and edema, which produces an area of low ventilation with normal perfusion. Capillaries become engorged with blood causing stasis. Clinical findings: cough, fever, flu – like symptoms, recurrent shaking chills, bloody or purulent sputum, and abnormal lung sounds. ABG’s may vary, pulse oximetry may show a reduced arterial oxygen saturation level. Chest x-rays confirm the diagnosis by disclosing infiltrates,
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careplan2 - 12/03, 11/05 STUDENT NAME Christina Liebdzinski...

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