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    NCP

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    Jiezl Abellano Afinidad
    Jenny Kim, a 39-year-old secretary, was admitted to the hospital with pneumonia. She presented with an elevated temperature, fatigue, rapid and labored breathing, and mild dehydration. Her medical history revealed she had been smoking a pack of cigarettes per day for over 20 years and had been dieting while also attending college classes, causing her to skip meals. A chest X-ray confirmed she had right lobar infiltration consistent with pneumonia.

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    NCP

    Uploaded by

    Jiezl Abellano Afinidad
    85 views2 pages
    Jenny Kim, a 39-year-old secretary, was admitted to the hospital with pneumonia. She presented with an elevated temperature, fatigue, rapid and labored breathing, and mild dehydration. Her medical history revealed she had been smoking a pack of cigarettes per day for over 20 years and had been dieting while also attending college classes, causing her to skip meals. A chest X-ray confirmed she had right lobar infiltration consistent with pneumonia.

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    Jenny Kim, a 39-year-old secretary, was admitted to the hospital with pneumonia. She presented with an elevated temperature, fatigue, rapid and labored breathing, and mild dehydration. Her medical history revealed she had been smoking a pack of cigarettes per day for over 20 years and had been dieting while also attending college classes, causing her to skip meals. A chest X-ray confirmed she had right lobar infiltration consistent with pneumonia.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    85 views2 pages

    NCP

    Uploaded by

    Jiezl Abellano Afinidad
    Jenny Kim, a 39-year-old secretary, was admitted to the hospital with pneumonia. She presented with an elevated temperature, fatigue, rapid and labored breathing, and mild dehydration. Her medical history revealed she had been smoking a pack of cigarettes per day for over 20 years and had been dieting while also attending college classes, causing her to skip meals. A chest X-ray confirmed she had right lobar infiltration consistent with pneumonia.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    Jenny Kim is a 39 year old secretary who was admitted to the hospital with an

    elevated temperature, fatigue, rapid, labored respirations, and mild dehydration.


    The nursing history reveals that Ms. Signh has had a ‘bad cold’ for several weeks
    that just wouldn’t go away. She has been dieting for several months and skipping
    meals. Ms. Signh mentions that in addition to her full-time job as a secretary, she is
    attending college classes two evenings a week. She has smoked one package of
    cigarettes per day since she was 18 years old. Chest x-ray confirms pneumonia.

    Physical examination data:


    Height: 167.6 cm
    Weight: 54.4 kg (120 lb)
    Temperature: 39.4 degree C
    Pulse: 68 beats/min
    Blood pressure: 118/70 mmHg
    Skin pale: cheeks flushed, chills, use of accessory muscles, inspiratory, crackles with
    diminished breath sounds right base, expectorating thck, yellow sputum.

    Diagnostic Data:
    Chest xray: right lobar infiltration
    WBC: 14,000
    pH: 7.49
    PaCO2: 33 mmHg
    HCO3 - : 20 mEq/L
    PaO2: 80 mmHg
    O2SAT: 88%

    Etiology (cause, predisposing/precipitating) (identify specifically the


    causative/predisposing/precipitating factors if applicable)

    Disease Process (the process should be presented in a cause-effect maner. The use
    of multiple boxes in presenting the disease process is expected)

    SIGNS AND SYMPTOMS (identify what are the signs and sym ptoms that will be
    associated for each significant landmark in the disease process)

    Signs: elevated temperature 39.4 degree C, fatigue, rapid, labored


    respirations, and mild dehydration.
    Symptoms:
    DIAGNOSTIC TOOLS (alongside the s/sx, state the diagnostic tools needed to detect
    the said s/sx):

    1. Chest Xray – to look for inflammation in the patient’s lungs (right lobar
    infiltration)
    2. CBC – to see whether the immune system is fighting an infection.
    3. Pulse oximetry – to measure how much oxygen is in the blood of the
    patient.
    4. Arterial Blood Gas – to measure the acidity, oxygen, and carbon dioxide
    levels of the blood.

    Management (alongside the s/sx, state the management, medical first, then
    pharmacologic, then nursing management, that will be performed vis-à -vis the
    identified s/sx)

    If not treated (continue the tracing resenting what will happen if the patient will not
    be treated)

    If treated (continue the tracing presenting what will happen if the patient will be
    treated with expected management. Present the management as well)

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