Pneumonia - bacterial pneumonia- Most bacteria enter the lungs through aspirations of organisms through the nose or throat.

Once in the lungs, the bacteria may infect the spaces between cells and between the alveoli where the white blood cells, more specifically neutrophils and macrophages attempt to disable the bacteria. Neutrophils then release cytokines, which activate the immune system leading to chills, fever, and fatigue that are most common in bacterial pneumonia. These neutrophils, macrophages, and fluid from surrounding blood vessels fill the alveoli which results in the darkened consolidated areas seen on chest x-rays. S/S - cough, fever, tachypnea, SOB, chills, tachycardia, chest pain that worsens with coughing, fatigue, weakness, nausea, vomiting, diarrhea

PATIENT DATA 50 YO CAUCASIAN MALE SMOKES 1PK/DAY DRINKS 2-3 BEERS/DAY MED HX: HTN

FOCUSED ASSESSMENT/LABS/DIAGNOSTIC STUDIES/MEDICATIONS/DIET/TREATMENTS Subjective Data: Sudden onset of fever accompanied by convulsions, weakness, shortness of breath, fatigue, insomnia, coughing up phlegm, nausea, vomiting, no appetite, weight loss, sometimes diarrhea Objective Data: cyanosis of the mouth and nose, dry skin with poor turgor, tiredness, tachypnea, dyspnea, bronchial breath sounds, crackles, breathing using accessory muscles, dullness found in percussion, lethargy, communication substandard, orientation x3 poor, laboratory results, leukocytosis, increased erythrocyte sedimentation rate, abnormal blood gas analysis, Labs and DX. Test - Chest X-ray, sputum cultures, pulse oximetry, various blood tests and cultures (to determine the type of organism causing the infection). In people 65 years or older, pleural fluid cultures and bronchoscopies are also used. Medication- Glucocorticoids, amoxicillin, clavulanate (Augmentin), fluroquinolone, IV cephalosporins, asprin or ibuprophen (to help with fever) Diet- increase fluid intake

Main Nursing diagnosis Ineffective Airway Clearance

EXPECTED OUTCOMES Effective airway Adequate ventilation No buildup No SOB Cough with sputum production

1. Ineffective Airway Clearance r/t inflammation 2. Ineffective Airway Clearance r/t accumulation of secretions

NURSING INTERVENTIONS 1. Monitor and record vital signs to establish baseline data 2. Help pt with breathing exercises frequently to help facilitate the maximum expansion of the lung 3. Exploitation as indicated to stimulate cough or mechanical airway clearance in patients who are unable to perform due to ineffective cough or decreased level of consciousness. 4. Encourage warm fluid intake (at least 2500 ml/day) warm liquids aid in mobilizing and removing secretions

EVALUATION OF OUTCOMES No SOB Cough with Sputum production

"Bacterial Pneumonia ." Bacterial Pneumonia. N.p., n.d. Web. 23 Nov. 2013.