NURSING CARE PLAN

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION /

DIAGNOSIS INTERVENTION OUTCOME
Subjective Cues: Independent:

> Child states, “Mom, Ineffective breathing Within 8 hours, Established rapport > Rapport is Goal met. Patient
my chest feels heavy pattern related to patient will exhibit important to gain exhibits a normal and
when I breathe.” inflammatory effects normal and effective patient’s cooperation effective respiratory
of pneumonia respiratory pattern as and reduce anxiety. pattern as evidenced
evidenced by: by:
Obtained resting vital > Baseline data is
> respirations within signs important to help > respirations within
acceptable range determine patient’s N range
(A state in which an current health status
individual’s inhalation > absence of signs and and evaluate efficacy > absence of signs and
Objective Cues: and/or exhalation symptoms of cyanosis of nursing symptoms of cyanosis
pattern does not interventions
> T= 39.2°C, P= 150, enable adequate > normal ABG and O2 rendered. > normal ABG and O2
RR= 46 pulmonary inflation or saturation levels saturation levels
emptying.) Placed patient in a > An upright position
semi-Fowler’s to high- promotes lung
> nasal flaring with Fowler’s position expansion and
shallow breathing mobilization of
secretions.
> use of accessory
muscles Repositioned patient q > Frequent
2h repositioning prevents
> crackles auscultated pooling and stasis for
in ® upper lobe secretions.

> productive cough Assessed patient’s > Frequent assessment

with thick purulent vital signs and provides information
sputum observed for signs and about any
symptoms of cyanosis improvement or
> diaphoresis & pallor q2h deterioration in
patient’s condition.
> increased WBC
count Encouraged increase in > Warm liquids aid in
oral fluid intake; mobilization of
> CXR= patchy offered warm liquids secretions.
diffusion in ® upper
and middle lobes

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 Maintained a quiet, > Promotes rest and
comfortable sleep and prevents
environment anxiety thereby
decreasing the
patient’s oxygen
demands
Dependent:

Administered > Bronchodilators aid

medications as in reduction of
ordered: antibiotics, bronchospasm.
mucolytics, Mucolytics and
expectorants, and expectorants mobilize
bronchodilators secretions. Antibiotic
therapy is prescribed
for pneumonia (except
lipid and viral
pneumonia).
Administered > Supplemental oxygen
supplemental oxygen aids in ventilation and
via face mask as minimizes the risk for
ordered hypoxemia.
Used play to > Play enhances
encourage child to participation.
cough and deep Coughing and deep
breathe; involved breathing promotes
parents in said maximum ventilation.
activities Involving parents
promotes active
participation.
Provided parents and > The patient and
patient with health parents should be
teachings on : taught the basics of
a. care of used tissues infection control to
b. proper prevent transmission
handwashing of microorganisms.
techniques
c. covering of mouth
and nose when
coughing or blowing
nose

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 Collaborative:

Monitored serial xrays, > Serial diagnostic

ABGs, and pulse studies follow the
oximetry readings progress and effects of
disease
process/therapeutic
regimen, and
facilitates necessary
alterations in therapy.

Assisted
with/monitored > Facilitates removal
effects of nebulizer of secretions to
treatments, chest promote a normal and
physiotherapy, and effective respiratory
incentive spirometry pattern.

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