Primary Nursing Diagnosis

Infection related to the presence of bacteria

OUTCOMES. Immune status; Risk control; Risk detection; Nutrition status; Treatment behavior: Illness or injury; Hydration; Knowledge: Infection control

INTERVENTIONS. Infection control; Infection protection; Surveillance; Fluid/electrolyte management; Medication management; Temperature regulation

U PLANNING AND IMPLEMENTATION Collaborative

PHARMACOLOGIC. Antibiotics can be administered before test results are available. The drug of choice is erythromycin. Intravenous fluids and electrolyte therapy may be considered when the patient has fluid volume deficit. Careful monitoring of fluid balance is required because of the possible renal complications from interstitial nephritis or renal failure. If renal failure does ensue, the patient may require temporary renal dialysis.

Oxygen per cannula at 2 to 4 L/min is effective with many patients, although in some patients with respiratory insufficiency, it is necessary to proceed with intubation and assisted ventilation. Atelectasis may occur at any stage of the pneumonia. Pleural effusion may occur, which may require a diagnostic thoracentesis and a chest tube. The patient may need continuous pulse oxime-try to monitor the response to mechanical ventilation and suctioning. Continuous cardiac monitoring and hourly urine outputs may be necessary to assess the patient's response to the disease.

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