Student Nurses’ Community

NURSING CARE PLAN ─ Pneumonia

Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

Subjective: Ineffective Ariway Bacterial/ Viral Invasion Short term goal: Independent:
“Nahihirapan akong Clearance related to the  Deep breathing After 8 hours of
humingi (It’s difficult to increased production of After 8 hours of nursing  Encourage deep promotes oxygenation nursing intervention,
breathe)” as verbalized by respiratory secretions intervention, secretions breathing exercises before controlled goal partially met.
the patient. will be mobilized, airway  Assist patient in coughing The patient was able
Multiplication of patency will be coughing exercises  To improve to > demonstrate
Objective: bacteria /virus; enters maintained free of  Increase fluid intake, productivity of the coughing and deep
 Rapid breathing/ the luns secretions, as evidenced as appropriate cough. breathing exercise
tachypnea patient’s ability to  Monitor rate,  Adequate fluid intake every 1-2 hours during
 Cough with yellow effectively cough out rhythm, depth, and enhances liquefaction the day
sputum production secretions, clear lung effort of of pulmonary
 Diminished and Cells of the immune sounds, and respirations. secretions and > Client’s respiratory
adventitious breath system gathers in lungs uncompromised  Assist patient into facilitates rate is within normal
sounds (crackles) to stop infection respiratory rate. moderate high back expectoration of range (RR – 19)
 Dyspnea rest position mucus.
 VS taken as follows:  Auscultate lung  Provides a basis for > Inspiratory crackles
fields, noting areas evaluating adequacy can still be heard at
T – 36.9 C of decreased of of ventilation the right lower lobe
P – 89 bpm absent airflow and  To promote drainage
RR – 36 br/min Inflammation & adventitious breath of secretions and > cough continues to
BP – 130/80 mmHg production of secretions sounds better lung expansion be productive.
increase  Decreased airflow
occurs in areas
Dependent: consolidated with
 Administer ordered fluid. Bronchial breath
Pulmonary infection medications such as sounds (normal over
mucolytic agents, bronchus) can also
bronchodilators, occur in consolidated
 Student Nurses’ Community
sputum production; expectorants areas. Crackles,
excess, accumulated  Administer rhonchi, and wheezes
secretion in the airways nebulizations as are heard on
needed inspiration and/or
expiration in response
to fluid accumulation,
airway blockage thick secretions, and
airway
spasm/obstruction.
 To help loosen and
clear the mucus from
the airways
(mucolytics); decrease
resistance in the
respiratory airway and
increase airflow to the
lungs
(bronchodilators) and
to loosen and clear
mucus and phlegm
from the respiratory
tract (expectorants)
 A variety of
respiratory therapy
treatments may be
used to open
constricted airways
and liquefy secretions.

Sources:

http://wps.prenhall.com/wps/media/objects/3918/4012970/NursingTools/ch50_NCP_IneffAirClear_1395-1396.pdf