You are on page 1of 3

Katrina Bianca M.

Palanca

RLE 6.2
NURSING CARE PLAN

Assessment






restlessness
irritability
nasal flaring
diaphoresis
tachycardia; PR =
122
has difficulty in
breathing

Nursing
Diagnosis
Impaired gas
exchange
related to
alveolarcapillary
membrane
changes
secondary to
inflammation

Analysis

Goal and
Objective
s

Intervention

Rationale

Evaluation

Bronchospasm
, which occurs
in many
pulmonary
diseases,
reduces the
caliber of the
small bronchi
and may
cause
dyspnea,
static
secretions and
infections.
Bronchospasm
can
sometimes be
detected by
stethoscope
when
wheezing or
diminished
breath sounds
are heard.
Increase

After 6
hours
of nursing
intervention
s the
patient will
demonstrat
e ease in
breathing.

1. Assess respiratory
rate, depth, and
ease.

1. Manifestations of
respiratory distress are
dependent on/and
indicative of the degree
of lung involvement and
underlying general health
status.
2. Cyanosis of nailbeds
may represent
vasoconstriction or the
body’s response to
fever/chills; however,
cyanosis of earlobes,
mucous membranes, and
skin around the mouth is
indicative of systemic
hypoxemia.
3. Restlessness, irritation,
confusion, and
somnolence may reflect
hypoxemia or decreased
cerebral oxygenation.
4. Tachycardia is usually
present as a result of
fever and dehydration

After 6 hours
of nursing
interventions
the patient
have
demonstrated
ease in
breathing.

2. Observe color of
skin, mucous
membranes, and
nailbeds, noting
presence of
peripheral cyanosis
(nailbeds) or central
cyanosis.
3. Assess mental
status.

4. Monitor heart rate
and rhythm.

comfortable room temperature. copious amounts of pink/bloody sputum. 6. High fever greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation. 5. Shock and pulmonary edema are the most common causes of death in pneumonia and require . contributes to further reduction in the caliber of the bronchi and results in decrease air flow and decrease gas exchange. arrange for significant other and visitors to stay with patient as indicated. 6. Prevents overexhaustion and reduces oxygen consumption and demands to facilitate resolution of infection. Maintain bedrest. Assist with comfort measures to reduce fever and chills.g. Monitor body temperature. 8. 8. noting hypotension. Assess level of anxiety. Providing reassurance and enhancing sense of security can reduce the psychological component. 5. and tepid or cool water sponge bath. 7. Anxiety is a manifestation of psychological concerns and physiological responses to hypoxia. thereby decreasing oxygen demand and adverse physiological responses.. Observe for deterioration in condition. but may represent a response to hypoxemia. Encourage verbalization of concerns/feelings.mucous production along with decrease mucous ciliary’s action. addition/removal of bedcovers. 7. as indicated. Answer questions honestly. e. Visit frequently. Encourage use of relaxation techniques and diversional activities.

pallor. cyanosis. and restlessness. and change in level of consciousness. . severe dyspnea. immediate medical intervention.