Pneumonia

Annotations:

• Fatique, weakness, insomnia, prolonged immobility and bed rest. Loss of appetite, n/v, lethargy, decreased tolerance to activity, tachycardia, neurosensory changes such as confusion, somnolence(drowsiness), ineffective neuro ck response  on the left foot. Small lesion on the left lower arm. Patient on contact precaution.

1. Loss of appetite, n/v
2. Prolonged immobility and bed rest
3. Decreased tolerance to activity
4. Ineffective neuro ck response on the left foot.
5. Pt. on contact isolation.

Annotations:

• Ineffective airway clearance, may be related to tracheal bronchial inflammation possibly evidenced by changes in rate and  depth of respiration. Impaired gas exchange maybe related to altered oxygen- carrying capacity of blood, possible evidenced by dyspnea  hypoxia. Activity intolerance maybe related to inbalance between oxygen supply and demand, general weekness. Exhaustion associated with interruption in usual sleep pattern because of discomfort , coughing possibly evidenced by verbal report of weakness, fatigue, tachypnea, tachycardia in responce to activity.Pt. on contact precaution due to  MRSA. 

1. Ineffective airway clearance
2. Activity intolerance
3. Tachycardia in response to activity
4. Pt. on contact precaution due to MRSA

Annotations:

• Patient will be evaluated about  response to activity. Report of dyspnea, increased weakness and fatigue, changes in vital signs during and after activities will be noted. Pt. will be assisted with self care activities as necessary.

1. Monitor changes in V/S during and after activity.
2. Assist with self care and other ADLs as necessary.
3. Assess for dyspnea, weakness and fatique.
4. Evaluate response to activities

Annotations:

• Patient will report and demonstrate a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue with vital signs within patient's acceptable range. Patient will demonstrate improved ventilation and oxygenation of tissues by ABGs within clients acceptable range and absence of symptoms of respiratory distress. Patient will identify and demonstrate behavior to achieve airway clearance by elevating the head of bed to fowler position, turning regularly and using flow meter at intervals.

1. Pt will demonstrate absence of symptoms of respiratory distress.
2. Pt will demonstrate a measurable increase in tolerance to activities
3. Pt. will demo. improved ventilation and oxygenation of tissues by ABGs.
4. Pt. will change positions and use flow meter at intervals.

Annotations:

• Patient did not verbalized understanding of condition, disease process and prognosis.  Pt. demonstrated  a small measurable increase in tolerance activities with less noted  sob, fatigue and VS within normal range. Overall the goals were not completely made, however patient has been helped around the clock by family members rotating between mother and daughter.

1. Pt. demonstrated a small measurable increase in tolerance activities by eating.
2. Pt. oxygenation and ventilation improved sats up 99%
3. Pt. V/S within normal limits.
4. Pt. was unable to change position without assistance