Student Nurses’ Community NURSING CARE PLAN ─ Pneumonia Assessment
Diagnosis
Inference
Planning
Intervention
Subjective: “Nahihirapan aong humingi !It"s #i$cult to breathe%& as verbali'e# b( the patient)
Ine9ective Ari-a( ,learance relate# to the increase# pro#uction of respirator( secretions
5acterial+ .iral Invasion
Short term goal:
In#epen#ent:
After 4 hours of nursing intervention> secretions -ill be mobili'e#> air-a( patenc( -ill be maintaine# free of secretions> as evi#ence# patient"s abilit( to e9ectivel( cough out secretions> clear lung soun#s> an# uncompromise# respirator( rate)
*bjective: Rapi# breathing+ tach(pnea ,ough -ith (ellosputum pro#uction Diminishe# an# a#ventitious breath soun#s !cracles% D(spnea .S taen as follo-s: / 0 12)3 , P 0 43 bpm RR 0 12 br+min 5P 0 617+47 mm8g
ultiplication of bacteria +virus; enters the luns
,ells of the immune s(stem gathers in lungs to stop infection
In
Rationale
Encourage #eep breathing e?ercises Assist patient in coughing e?ercises Increase as appropriate onitor rate> rh(thm> #epth> an# e9ort of respirations) Assist patient into mo#erate high bac rest position Auscultate lung @el#s> noting areas of #ecrease# of absent air
Deep breathing promotes o?(genation before controlle# coughing /o /o improve pro#uctivit( of the cough) A#euate
Evaluation
After 4 hours of nursing intervention> goal partiall( met) /he patient -as able to B #emonstrate coughing an# #eep breathing e?ercise ever( 6C hours #uring the #a( B ,lient"s respirator( rate is -ithin normal range !RR 0 63% B Inspirator( cracles can still be hear# at the right lo-er lobe B cough continues to be
Student Nurses’ Community
Pulmonar( infection
sputum pro#uction; e?cess> accumulate# secretion in the air-a(s
air-a( blocage
Depen#ent: A#minister or#ere# me#ications such as mucol(tic agents> broncho#ilators> e?pectorants A#minister nebuli'ations as nee#e#
Decrease# air rhonchi> an# -hee'es are hear# on inspiration an#+or e?piration in response to thic secretions> an# air-a( spasm+obstructio n) /o /o help loosen an# clear the mucus from the air-a(s !mucol(tics%; #ecrease resistance in the respirator( air-a( an# increase air
pro#uctive)
Student Nurses’ Community
Sources: http:++-ps)prenhall)com+-ps+me#ia+objects+1364+763F7+Nursing/ools+chG7HN,PHIne9Air,learH613GC6132)p#f
lungs !broncho#ilators% an# to loosen an# clear mucus an# phlegm from the respirator( tract !e?pectorants% A variet( of respirator( therap( treatments ma( be use# to open constricte# air-a(s an# liuef( secretions)
