Nursing assessment Pneumonia

Nursing assessment

  • Subjective Data
    • Important Health Information
      • Past health history:
        • Lung cancer, COPD, diabetes mellitus, chronic debilitating disease, malnutrition, altered consciousness, immunosuppression, exposure to chemical toxins, dust, or allergens
      • Medications:
        • Antibiotics, corticosteroids, chemotherapy, or any immunosuppressants
      • Surgery or other treatments:
        • Recent abdominal or thoracic surgery, splenectomy, endotracheal intubation, or any surgery with general anesthesia. Tube feedings
    • Functional Health Patterns
      • Health perception–health management:
        • Cigarette smoking, alcoholism; recent upper respiratory tract infection, malaise
      • Nutritional-metabolic:
        • Anorexia, nausea, vomiting. Chills
      • Activity-exercise:
        • Prolonged bed rest or immobility. Fatigue, weakness. Dyspnea, cough (productive or nonproductive). Nasal congestion
      • Cognitive-perceptual:
        • Pain with breathing, chest pain, sore throat, headache, abdominal pain, muscle aches