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HLTAAP003 Analyse And Respond To Client Health Information

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HLTAAP003 Analyse And Respond To Client Health Information

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Course Code: HLTAAP003
University: Victoria University

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Country: Australia

Analyse and Respond to the Client Health Information.

Pneumonia is a disease which affects the lung and usually portrayed by the airspaces (alveoli) in the lungs being inflamed, mostly as a result of infection. Causes of pneumonia include infections caused by viruses, bacteria or fungi. It is a more serious disease especially when in infects young children and infants or the elderly since there immune system is weak. Those with weakened immunity for example, those suffering from HIV/AIDS also get affected much when they get infected with pneumonia. Pneumonia can be classified as Hospital-acquired pneumonia, community-acquired pneumonia and aspiration pneumonia. Hospital-acquired pneumonia develops when a person is already in the hospital premises whereas community-acquired is acquired outside the healthcare environment. Aspiration pneumonia on the other hand is as a result of food, drink, vomit or saliva inhalation when the swallowing reflex is ineffective. Pneumonia may also be classified according to the causative agent, for example bacterial pneumonia or viral pneumonia. Most types of pneumonia are contagious and may easily spread from one person to another through inhalation of droplets from sneeze or even cough (La Rosa, Fratini, Libera, Iaconelli,. and Muscillo, 2013 pp. 124-132).
Pathophysiology of Pneumonia
When an organism such as bacteria, fungi or virus reaches the lungs they trigger an immune response (Singh 2012, pp. 7-9). This makes the neutrophils to engulf the invading pathogen and cytokines are released. This leads to inflammatory reactions. The lungs become hyperaemic. Fluid shifts from the intravascular spaces into the alveoli and lung tissue since the capillaries become highly permeable. This results to impairment of ventilation as the gaseous exchange space become less. Congestion of the lungs therefore ensues due to the fluid shifting. The lungs appear hard and red. This is shown by the large amount of confluent exudates by red blood cells, fibrin and neutrophils which fills the alveolar space. The hyperemia then reduces however the lungs is still hard. It becomes gray in appearance since the red blood cells becomes disintegrated continuously and the fibrin suppurative exudates persist. This is attained by the reduction of blood to the lungs and the fibrin and leukocyte consolidate in the part that is affected (Driver 2012, pp. 103-106). This is followed by the resolution of the infection whereby the pulmonary structure is restored. The exudates that are consolidated in the lungs are digested enzymatically and the macrophage ingest most debris which are coughed out thereafter. The lungs can then return normal and gaseous exchange resume if complete resolution occur.
Signs and symptoms of pneumonia
The clinical manifestation of pneumonia ranges from mild to severe. This is dictated by factors like age, health or the type of causative pathogen. The signs and symptoms of pneumonia may include: chest pain which is felt when one coughs or breathe, coughing which may be productive (mucus), fever and chills is also experienced and fatigue. One may also experience nausea, vomiting and diarrhea. Shortness of breath is also usually manifested. The patient mental status may also change and the patient become confused.
Significance of Mr. Smith’s Vital signs in relation to the presenting problem
Mr. respiratory rate is 36 breaths per minute which is high above the normal range of 12 to 20 breathes per minute in adult. This is significant in relation to his presenting condition since pneumonia causes lung congestion thus interfering with the normal gaseous exchange. Oxygen is therefore not supplied sufficiently to the body and as a result its demand increases. The body therefore tries to increase the oxygen supply by increasing the respiratory rate. The patient therefore breaths faster making it even difficult for him to talk normally. The temperature is 39.3? C. Fever is a classical sign of infection. this occurs in Mr. Smith due to inflammation in the alveoli as the body attempts to kill the infection (Ward 2010, pp.1-16). The high temperature may cause profuse sweating, high rate of breathing and increase in pulse rate. However, Mr. Smith pulse rate of 146 beats per min may be due the hypertension that he is suffering from. The blood pressure of 189/98 is also above the normal range but this is relating to his past medical history of hypertension. The oxygen saturation level of 82 % is below the normal (>95%) and this is because of inadequate oxygen supply.
Significance of Mr. Smith history in relation to his presenting problem
Mr. Smith have been previously diagnosed with type 2 diabetes. Diabetic patient has been known to be at increased risk of suffering from infections such as pneumonia. This is because diabetes lowers the immune system of the body (Yende et.al 2011 pp. 870-877). Hence the body will easily get pneumonia as it will not have enough defense mechanism. He also has a history of bronchitis. Bronchitis is an infection of pulmonary system and if proper treatment is not sought then it may travel into the lungs which may cause pneumonia. Pneumonia will also put him at risk due to his hypertensive nature. Research done have shown that this can cause death. This is because the pulmonary infection may not be tolerated by the lung.
Treatment options for Pneumonia
Pneumonia can be treated through medications and supportive care. Medications used are antibiotics such as penicillin. The antibiotics will terminate the growth of bacterial and kill it (Leekha, Terrell, & Edson 2011 pp. 156-167). Other medications may include analgesic to relieve pain and cough medicine which help to calm coughing. Supportive therapy will involve: oxygen therapy, oral rehydration therapy and iv fluids. Oxygen therapy will aid in improving the oxygen supply to the bloodstream while the oral rehydration therapy and iv fluids is given to cover up for the lost fluid in case of vomiting and diarrhea. 
Care plan








Mr. smith verbalizes that the chest pain is ”sharp”
Use of accessory muscle
RR of 36beats/ min

Ineffective airway clearance related to tracheal bronchial inflammation increased sputum evidenced by use of accessory muscle and changes in rate and depth of respirations

pneumonia is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria

After 10hours of nursing intervention the patient will identify behaviors to achieve airway clearance absence of dyspnea and cyanosis

auscultate lung fields noting areas of absent airflow and adventitious sound
Teach and assist patient with proper deep breathing exercises. Demonstrate proper splinting of chest and effective coughing to him while in upright position .

Decreased airflow occurs in areas of consolidated fluid crackles, rhonchi and wheeze are heard on inspiration and on expiration in response to fluid accumulation thick secretions and airway spasms and also obstruction
Deep breathing exercises facilitates maximum expansion of the lungs and smaller airway coughing is a reflex and a natural self-cleaning mechanism that assist the cilia to maintain patent airways, splinting reduces chest discomfort and upright position favors deeper and more forceful effort

After 10 hours of intervention respiratory rate became 21 breaths per minute and chest pain reduced

Capillary refill of more than 5 seconds
Blood pressure of 18998
Oxygen saturation of 82 %
Pulse of 146b/min

Impaired gaseous exchange related to altered oxygen carrying capacity of blood evidenced by capillary refill of more than five seconds


After 8 hours of nursing intervention the patient will demonstrate improved ventilation and oxygenation of tissues within acceptable range and absence of symptoms of respiratory distress

Administer oxygen therapy through non rebreather mask  10l min

Oxygen therapy is to maintain pa oxygen above 60mmhg and increases oxygen saturation (Schmidt et.al 2013, pp. 838-846)

After 8 hours of nursing intervention capillary refill of less than 3 seconds
And oxygen saturation of 98%

List of references
Driver, C. (2012). Pneumonia part 1: pathology, presentation and prevention. British Journal of Nursing, 21(2), 103-106.
La Rosa, G., Fratini, M., Libera, S.D., Iaconelli, M. and Muscillo, M., 2013. Viral infections acquired indoors through airborne, droplet or contact transmission. Annali dell’Istituto superiore di sanita, 49, pp.124-132.
Leekha, S., Terrell, C. L., & Edson, R. S. (2011, February). General principles of antimicrobial therapy. In Mayo Clinic Proceedings (Vol. 86, No. 2, pp. 156-167). Elsevier.
Schmidt, M., Tachon, G., Devilliers, C., Muller, G., Hekimian, G., Bréchot, N., Merceron, S., Luyt, C.E., Trouillet, J.L., Chastre, J. and Leprince, P., 2013. Blood oxygenation and decarboxylation determinants during venovenous ECMO for respiratory failure in adults. Intensive care medicine, 39(5), pp.838-846.
Singh, Y.D., 2012. Pathophysiology of community acquired pneumonia. Supplement to JAPI, 60, pp.7-9.
Ward, P.A., 2010. Acute and chronic inflammation. Fundamentals of inflammation, pp.1-16.
Yende, S., van der Poll, T., Lee, M., Huang, D.T., Newman, A.B., Kong, L., Kellum, J.A., Harris, T.B., Bauer, D., Satterfield, S. and Angus, D.C., 2010. The influence of pre-existing diabetes mellitus on the host immune response and outcome of pneumonia: analysis of two multicentre cohort studies. Thorax, 65(10), pp.870-877.

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