Nursing Assessment Report: Analysis of Patient Case Study Details

This nursing assessment report analyzes a patient case study involving pneumonia, detailing the patient's condition, and outlining a comprehensive plan of care. The report begins with an introduction to nursing assessment, emphasizing its role in gathering patient information for effective care planning. It then delves into the pathophysiology of pneumonia, explaining the infection's impact on the lungs and the various types of pneumonia. The clinical manifestations of the disease, including breathing difficulties, fever, and other symptoms, are discussed in detail. The report also covers the nursing management strategies, which include focused respiratory assessments (inspection, palpation, and auscultation), escalation protocols, oxygen management, pharmacological interventions (antibiotics and pain relievers), and psychosocial support. The report underscores the importance of collaborative management and provides a plan of care, ensuring patient safety and well-being. The report also includes references in APA 6th edition format, adhering to the assignment's requirements.

Running Head: NURSING ASSESSMENT 1
Nursing Assessment.
Name of Institution.
Student Number.
Due date.
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Running Head: NURSING ASSESSMENT 2
Introduction.
Nursing Assessment is aimed at gathering information related to the patient, thus it is the
beginning of the nursing process. It is a step by step procedure that cannot be avoided to ensure
patient safety. The assessment also helps to identify the abilities of a patient (Giger, 2016 ). The
assess activity may be comprised of observations of the patient to see the signs and symptoms
and looking at the medical and the social history of the patient (Kuhn & Elliott. 2013). It
identifies the needs of a patient and it touches across pathophysiology, clinical manifestation,
nursing management, and collaborative management. Therefore, it is very important for
providing information to be used in establishing a nursing care plan.
Pathophysiology.
Pathophysiology is a discipline that points on the signs and the functions of an organ that
is diseased for diagnosis and patient care. It is a fundamental aspect in the nursing practice as it
enables the nurses to build affirm foundation (DiBardino, & Wunderink, 2015). Therefore, the
knowledge can enable one to learn the physical abnormalities occurring due to a disease in the
body. It is a discipline that helps nurses to provide and ensure patients care by understanding all
the signs and symptoms exhibited by their patients.
Therefore, the pathophysiology of pneumonia is an infection that causes the abnormal
functionality of the lungs. This is caused by a viral or bacteria that affects the alveoli in the lungs
making it be filled up with fluid (Mandell, 2015). When infected a person show visible
symptoms which include, having difficulties while breathing, fever and coughing. As observed,
Tom did have difficulties in breathing where he had respiratory distress and increased accessory
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Running Head: NURSING ASSESSMENT 3
muscle use (Nicholson et al. 2013). The disease is more serious in children below five years and
adults above 65 years. It does affect people whose immune system is not strong.
The organ that is being studied here is the lungs to determine the extent of the illness. It
also existed in different forms; hence, a comprehensive study on patient health history must be
done. It is hence classified according to the type of bacteria causing it.
Types.
Community-acquired.
It occurs when the patient is outside the hospital hence is the most known type of pneumonia.
Therefore, it is brought about by bacteria, fungi, and viruses in the surrounding environment of
the patient.
Hospital-acquired.
This is very dangerous as it is gotten by people how are already ill in the first place and the have
weak immune systems. Also, the bacteria become resistant to antibiotics and most happens to
people with breathing problems and have been put in ventilators to aid them in breathing.
Aspiratory pneumonia.
This type is caused when a person inhales a substance into the lungs. The substances may
include, food, drinks or saliva. Also caused by use of alcohol and drugs excessively.
There Tom may have hospital-acquired pneumonia.
Clinical Manifestation.
The clinical manifestation is the signs and symptoms related to a disease. For a proper clinical
manifestation to be done the doctor must do comprehensive pathophysiology of pneumonia to
assert the disease existence (Roux, at al. 2014). Thus, the clinical manifestation for pneumonia is
characterized by:
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 Difficulties in breathing and chest pains. This is mostly seen when a person is coughing.
The patient may complain of straining. As illustrated in the case study Tom did have a
hard time breathing.
 Secondly, the patient experiences a high fever. The patients tend to seat abnormally while
shivering at some time which is ironical. Tom's temperature was reading 38.2 degrees
Celsius in comparison with the healthy persons 37 degrees Celsius.
 Moreover, he or she can experience shortness the breath rate. Therefore, the heart is
forced to work a lot to supply oxygen to the whole body. this way the heart rate become
abnormal like that of Tom which is at 125 beats per minute (Cole & Robertson. 2015).
 In addition to this, the patients may complain of fatigue while still in the hospital bed
without doing any work. This is due to the overworking of muscle that facilitates
breathing (Mahony. 2018)
 Furthermore, the patient may experience diarrhea, nausea, and vomiting. This is a very
dangerous clinical manifestation as it dehydrates the patient.
 Lastly, for older people, they may show signs of memory loss or confusion. The patient
tends to forget simple details and even becomes confused about the family members that
visit them in the hospital.
Respiratory Assessment.
This is a focused assessment aimed to further and deeply look at the body system, which in this
case it is the breathing system (Govindaraj & Riyaz.2014). Therefore, the nurse has to collect
information about the patient’s history by requesting signs such as cough and difficulties in
breathing (Hoskins. 2015). The essence of carrying this assessment id to ensure that no detail is
left in the process of workload to ensure patient safety (Rhedin. 2015). For the case of Tom, the
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assessment must be approached systematically to ensure all the details are well documented.
Therefore, the following components must be followed.
Inspection.
Being the first stage, its objective can be achieved in a split of seconds by assessing the
patient's general appearance (Roca, at al.2016). While approaching Tom it is very easy to
observe critically the health condition of him. The assessment starts here when I can focus on the
following observation. To start with is the mental status of Tom (Laurence & Webster. 2013).
Does he show any signs of being alert or need to be alerted in the first place? Moreover, I can
observe the breathing nature of him to see if he is struggling to inhale or he is in an artificial
airway system that is helping him to breathe effectively. I can also be the first sight look at Tom's
skin condition and his chest expansion. This way in a very short time the inspecting provides
useful information that can give me a clue on Tom's medical history.
Palpation.
This is a medical examination exercise that is done by using the hands. After observing Tom's
appearance, one can go further to feeling the condition of his chest. This is, therefore, a physical
assessment of the patient (Giusti, 2017). It can provide important information about the patient
which include: Tom’s temperature, the alignment of the tracheal and excursion. One can also the
crackling indicating air leakage in the lungs and carry out percussion to know the state of the
inner structures of the heart3Hoskins, W. J. (Ed.). (2015). Under this stage on could see that Tom
had a fever (Leiblum. 2016).
Auscultation.
This is the final and the most critical component of the assessment .it is aimed to listen to
abnormal sounds in the lungs. It must be done thoroughly in the entire surface. The main purpose
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is to ensure that all lobes in Tom's lungs are functioning properly. These sounds include crackles,
rhonchi and wheezing (Bohadana, Izbicki, & Kraman, 2017). In this case, study crackles are
heard in the right lower lobe indicating air passing over fluid that is present in the lungs. Form
this assessment one is confident that treatment must be done immediately.
Escalation.
Escalation is the care given to a patient, in this care Tom, to ensure that his or her health does
not deprive due to further harm caused by the disease. It is aimed in ensuring the Tom will not
worsen with time but improve in his health. The escalation processes that can be administered to
Tom include (Khasawneh, at al. 2014):
 Getting a lot of rest. This will help in his full recovery process. Tom will, therefore, be
able to heal without any worry of doing any activity.
 Also drinking plenty of fluid. This will help in the loosening of the secretions to release
the phlegm.
 Finally, making sure that he does not inhale any fumes or smoke and ensuring that the
beverages assigned to him are warm to open the airways and enhance proper breathing.
Oxygen management.
Due to the challenges Tom experience, while breathing, an oxygen management
procedure would work perfectly to help in-breathing properly. It will help his muscle to relax
hence provide an easy way out to recover while another medication is given to him (Osler.
2012). Therefore, the use of antibiotics and home care oxygen management is of the applied
treatment to a patient. The treatment comes in two ways, namely, mechanical ventilation and
nasal cannula (Brambilla, at al.2014). A tightly fitted mask can be used to or the insertion of a
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tube directly to the windpipe. In this case, Tom has to be administered with the use of masks to
help him breathe properly. This way his chance for survival is so high. The oxygen management
strategies include: applying face masks, wafting, nasal cannula and humidified oxygen
(Seemungal et al, 2011).
Pharmacological management.
Pharmacological management involves the treatment of the disease. Various strategies
can be used depending on the findings from the focused assessment (Rodrigo, Fernando &
Rajapakse 2014). Therefore, the main goal here remains to be curing the disease and prevent
further complication to be experienced by Tom. Moreover, the treatment depends on the type of
pneumonia, the overall health condition of the patient and the age. For them that acquired it in
the community which is not the case for Tom medication is administered while they are at home.
For this case study, Tom is in the hospital and two strategies must be used in his
pharmacological management procedure. These strategies are the use of antibiotics and
administering fever and pain relievers. The antibiotics are used to fight the bacteria causing
pneumonia (Sheldon et al. 2015). Therefore, due to the different type of bacteria that causes it
the one has to carefully assess to determine the best antibiotics to prescribe for Tom treatment.
After identification of the bacteria, one can know to administer the antibiotics and closely
monitor the response if to does not respond well to them, therefore a need to change then is
created and in this case, a new set of antibiotics is prescribed for him (Attygalle & Rodrigo, N.
2012).
The second strategy is to give him drugs that are going to offer him comfortability while
staying in the hospital. These drugs include painkillers and fever reducers. Due to the high
temperature of 38.2 degrees, Celsius Tom has to be given fever reducers. Pain is also
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experienced when breathing in the lungs due to small airways. Hence, pain relievers can be given
to him to ensure comfort while recovering. These types of drugs include aspirin, acetaminophen,
and ibuprofen.
Psychosocial management.
This is a management practice that goes beyond the use of drugs. It is applicable in the case of
pneumonia as it is practice on patients who have complex medical and psychosocial needs.
Mostly they are patients how do not have a home and have mental issues (Zuckerman. 2012).
While Tom or any other patient is experiencing fatigue, it can make him be physically and
mentally tired. In this way, signs of emotional stress and depression can be witnessed (Cappell,
2017). This is psychosocial effects that Tom may experience while under the medication and
need to be addressed.
Therefore, the following strategies are used in psychosocial management:
 Recreational activities
This strategy is meant to ensure that the patient stays happily. in this case, one should
make sure that Tom is not allowed to think a lot rather he should be having a joyous spirit
which will aid in his improvement.
 Support group.
This is one of the most important strategies. Here patients with pneumonia and those that
have overcome it, come together and encourage each other. It is aimed to bring hope to
the patients that are currently suffering from the disease.
 Therapy.
Finally, therapy helps the patient and the family to accept the condition at hand and move
forward towards recovery.
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Collaborative management.
This is a healthcare application aimed to better the patient's health by bringing on board
interprofessional. Different specialist for different health sector can together with one goal,
which is to help Tom recover from pneumonia(Parikh, et al. 2017 ). Furthermore, family and
friends are also brought on board in this process to aid in the quick recovery process. The
collaborative management practice does improve the patient safety and utilization of resources
hence highly recommendable in this case study.
Therefore, being a nurse, one is trained to understand all the other specialist in different
disciplines. Therefore, for Tom recovery one has to display great skills intercommunication,
adaptability, and empathy. Therefore, this makes one be the perfect leader among the team
providing treatment to Tom. Therefore, this process will lead to patient's satisfaction, promote
teamwork, increase morale by eradicating staff isolation and reducing the risks that could be
made out of a decision without consultation. To get collaborative management results of
teamwork the following strategies may be used:
 Developing a culture of respect.
Mutual respect will bring harmony to the team that is collaborating for the betterment of
Tom. This culture is implemented by putting across cultures that do promote friendliness
and prevent bullying of any kind.
 Usage of managers.
The essence of this strategy is to ensure that proper leadership and direction is given to all
the nurses in the team. They ensure harmony and appreciate the nurses that have done a
good job daily.
 Huddles.
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This strategy helps in encouraging interactive of the nurse with the patients. It provides a
platform of free expression of one’s suggestion and recommendation.
Allied Professionals.
They are involved in the whole process of treatment, prevention, and diagnosis of pneumonia.
They include:
 Respiratory technologists are responsible for investigating the way about of the patient in
terms of the lung volume airflow and the process of blood oxygenation.
 Respiratory physiotherapists are responsible for ensuring that the patient has a good
movement and functional ability.
 Respiratory nurses are responsible for taking care of the patients with pneumonia while
working together with other people in the team.
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
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