Case Background
A 75-year-old male patient with pneumonia is supine, coughing, struggling to breathe, and calling for help. The nurse finds the call bell on the floor, the walker across the room, the bed at its highest, the room cluttered, the ID band on a computer cart, and a urinal with dark urine on the bedside table. No fluids are available. His vitals: temp 100.9°F, pulse 110, BP 90/42, respirations 24, and pain 8/10.
Nursing Priority Interventions and Assessments
As a nurse, the priority interventions and assessments in this situation would include assessing the patient’s airway, breathing, and oxygenation. In the present case, the 75-year-old patient struggles with breathing and pneumonia. As a result, interpreting vital signs, examining the patient’s breathing pattern, skin tone, and state of respiration, palpating the patient for anomalies, and using a stethoscope to auscultate lung sounds are all part of a focused respiratory evaluation (Ernstmeyer & Christman, 2021).
Interpretation of the Vital Signs
As for the vital signs, they show a fever, low blood pressure, and an accelerated heart rate. These results raise the possibility of hemodynamic instability, infection, and dehydration (Chakraborty & Burns, 2023). In this situation, it is recommended to start an IV administration of fluids (Chakraborty & Burns, 2023). Moreover, assessing the pain response is crucial for a healthcare professional to pay attention to.
The Safety Issues in the Patient’s Room
Another point that is worthy of consideration is the safety of the patient’s room. There was a urinal on the bedside table, the patient’s call bell was on the floor, the bed was in its highest position, and the room was disorganized. According to Piatkowski and colleagues (2021), bells must be within the patient’s reach, the bed should be lowered for a comfortable position, and the environment must be clean.
The Necessity of Informing the Provider
As a nurse, I could also contact the provider to update them on the patient’s condition. In terms of SBAR, I would say that a 75-year-old male was admitted with pneumonia. They have pneumonia and demonstrate high temperature and blood pressure, and upon assessment, I found the patient lying supine, which necessitates a further evaluation to assess his respiratory status and fluid volume status.
The Care Plan and Patient Education
The patient’s plan of care is likely to involve antibiotics, supplemental oxygen as needed, and adequate rest (Taylor et al., 2022). I would educate the patient by explaining the purpose of his treatment and side effects and encourage fluid intake.
References
Chakraborty, R. K., & Burns, B. (2023). Systemic inflammatory response syndrome. National Library of Medicine. Web.
Ernstmeyer, K., & Christman, E. (Eds.). (2021). Chapter 10: Respiratory assessment. In Nursing skills. Chippewa Valley Technical College. Web.
Piatkowski, M., Taylor, E., Wong, B., Taylor, D., Foreman, K. B., & Merryweather, A. (2021). Designing a patient room as a fall protection strategy: The perspectives of healthcare design experts. International Journal of Environmental Research and Public Health, 18(16), 1-21. Web.
Taylor, C., Lynn, P., & Bartlett, J. L. (2022). Fundamentals of nursing: The art and science of person-centered care. Lippincott Williams & Wilkins.