Faulkner State Community College; Division of Nursing

NUR 201
Clinical Paperwork Data Sheet

Student Name Clinical Week _________________________

Date Client Initials Age Admission Date ________________

Instructor Clinical Area______________________________

Medical Diagnosis and Pathophysiology: (Be sure to list signs and symptoms). Please indicate your
source of information.

Aspiration/Pneumonia: Patient is diagnosed with aspiration pneumonia in the right lower lung.
Aspiration pneumonia refers to the pulmonary consequences resulting from the entry of endogenous or
exogenous substances into the lower airway. The most common form of aspiration pneumonia is bacterial
infection from aspiration of bacteria that normally reside in the upper airways. Aspiration pneumonia may
occur in the community or hospital setting; common pathogens are S. pneumoniae, H. influenzae, and
Staphylococcus aureus. Other substances may be aspirated into the lung, such as gastric contents,
exogenous chemical contents, or irritating gases. This type of aspiration or ingestion may impair the lung
defenses, cause inflammatory changes, and lead to bacterial growth and a resulting pneumonia. Aspiration of
stomach contents into the lungs is a serious complication. It can occur when the protective airway reflexes
are decreased or absent from a variety of factors. The primary factors responsible for death and complications
after aspiration of gastric contents are the volume and character of the gastric contents. A small, localized
aspiration from regurgitation can cause pneumonia and acute respiratory distress; a massive aspiration is
usually fatal. Aspiration of substances with a pH of less than 2.4 can result in the destruction of alveolar-
capillary endothelial cells, with a consequent outpouring of protein-rich fluids into the interstitial and intra-
alveolar spaces. As a result, surfactant is lose, which in turn causes the airways to close and the alveoli to
collapse. The impaired exchange of oxygen and carbon dioxide causes respiratory failure. Signs and
symptoms of aspiration pneumonia are fever, dehydration, tachycardia, dyspnea, hypertension, hypotension,
abnormal breath sounds (crackles, wheezes, rales) and central cyanosis. Prevention is the primary goal when
dealing with patients at risk for aspiration.

Medical-Surgical Nursing; Brunner & Suddarths 9 th Edition

List and prioritize any secondary diagnosis that has been identified for your client (Based on your patient's
problems).

1. Organic Brain Syndrome

2. Spina Bifida (Hemiplegic since birth)
3. Sever Osteoarthritis
4.