Pneumonia Case Study the General Statistics and Case Study

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Pneumonia Case Study

The general statistics and facts about the patient are as follows. The patient is a Caucasian whit e email that is 52 years old. She was admitted to St. Mary's hospital on 12/12/2012. She stood a bit over five feet tall and weighed around 128 pounds. She was married with two grown children and lives in a small camping trailer as opposed to a conventional home or apartment/room.

Both the patient herself and the spouse of the patient are of disabled status. Advanced directives for the patient were in force as of the date of admission of the patient, again that being 12/12/2012. The purpose of the admission on 12/12/2012 was for a pneumonectomy. The patient was prior-diagnosed with necrotizing pneumonia in August 2012 and she hoad a lobectomy in Sepbemter. However, the necrotizing pneumonia destroyed the rest of the patient's lung.

The patient in question had had a number of surgeries over her life numbering well into the double digits. These surgeries including a hysterectomy, a cervical laminectomy, a C-section, tubal ligation, breast reduction and knee surgery. The total surgery count stood at 18 in her lifetime. She was in the hospital for a total of 65 days, eventually being discharged on 2/14/2013. Overall health was greatly improved due to the surgery and the ensuing therapy and other treatment.

Functional Health Patterns

The functional health patterns for the patient were assessed on the 57th and 58th day of the patient's hospitalization, those days being 2/5/2013 and 2/6/2013. The sources of the information gathered for this report include the patient, the husband of the patient and the hospital staff.

Nutrition-Metabolic

As far as nutrition/metabolic information, the patient has the following general pattern of meals

Breakfast

Yogurt

Coffee

Lunch

Chicken

Salad

Dinner

One of any variety of soups

General Fluid Intake at any time

Water

Gatorade

Coffee

The patient said the following things about her appetite

Weight went from 128 pounds upon admission to nearly 100 pounds after the surgery

She gained about 20 pounds back after leaving ICU

No allergies

No trouble chewing

No difficulty swallowing

No difficulty chewing

Was 121 pounds upon discharge, only seven pounds lower than what she was upon admission.

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Physical Assessment

Had the following skin/health issues beyond what has been mentioned already

Dry itchy skin

Bruising

Skin graft necessary for right thigh

No signs of infection from the thigh wound

Wound on right side where 3 ribs had to be removed as part of lung removal

Right thing skin graft as noted above

Urine is pale yellow

No burning, burning or dribbling during urination

No assistive devices necessary for proper urination

Normal bowel elimination patterns as well, for the most part.

Once went two days with no bowel movement but eventually had a very large one

Very sedentary lifestyle with low outlook of that ever changing due to the oxygen being necessary, among other reasons.

No exercise

Main leisure activity is reading

If she exercises, she experiences fatigue, coughing and pain

Pain from the exercise is dull and all over the body

Will need daily assistance with some tasks

Tasks requiring assistance will include shopping, cooking and home maintenance.

Level of assistance needed daily tasks with five (V) being the highest and zero (0) being none

Feeding -- 0

Bathing -- I

Toileting -- I

Bed Mobility -- 0

Dressing -- 0

Grooming -- 0

General Mobility -- I (cane)

Cooking -- II

Home Maintenance -- IV

Shopping -- IV

Activity-Exercise

Activity and exercise shows as follows

Usual bed time -- 10 pm

Usual wake time -- 8 am

Rested after sleep? No…usually still very tired

Sleep rituals? No…not usually. Just taking pills and the like

Able to fall asleep? Yes

Able to stay asleep? No

Cognitive & Perceptual

Able to read and write? Yes.

Languages spoken? Only English

How do you learn best? Reading

Do you learn new things well? Yes.

Do you wear glasses? Only for reading

Last visual exam: July 2012

Dizziness issues? No

Sensitivity to Cold/Heat? Yes

Pain with cold/heat sensitivity? Yes

Self-perception/self-concept terms? Thankful, happy for support.

Changes in perception? Near-death experience….....

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