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puja929 puja929 (New) New

Okay so guys! I am going crazy. I've had tests all week and dont have energy to do this care plan but have no choice. Please help because I cant think of any diagnosis for my patient. He has a fever, abdominal and chest pain. He has pneumonia and HIV and high cholesterol. He doesnt have much sputum. He 37 years old; active, normal lab values; good nutritional status; good coping skills; loves his children! I CANT THINK OF MANY DIAGNOSIS :(

Hes on a lot of meds : Cipro, Saline, Cholesterol meds, HIV meds, infection meds

I have:

Ineffective Protection r/t depressed immune system

Acute Pain

Ineffective Breathing ( but his breathing is fine, respiratory rate 12, unlabored, isnt really coughing or blowing nose to notice sputum but I think its whitish - thats what he said)

Any thought or inputs?

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

he was diagnosed with pneumonia and was put on cipro. just because he doesn't have much sputum doesn't mean he doesn't have a lung problem going on. read about pneumonia. this is not like a cold. it is a serious infection. he has chest pain and with no other information my guess is that it is either due to the infection or muscle strain from coughing. did you listen to his lungs? were his lung sounds diminished over some lobes compared to others? he needs to be deep breathing and coughing to get the consolidated gung moving up and out of his lungs. your assessment evidence needs to be much more specific than what you have posted.

  • ineffective airway clearance r/t inflammation of lung tissues aeb ineffective cough [your assessment of his breath sounds]
  • hyperthermia r/t infectious process in lung aeb fevers of ____ [and other symptoms of fever]
  • acute pain r/t muscle strain aeb chest and abdominal pain

ineffective protection r/t depressed immune system

what evidence do you have of this? he is already has hiv and has an acute infection. what else does he need protection from? his system has already failed him.

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