NAME: GUERRERO, AUBREY MARIE BSN 4B

NURSING CARE PLAN FOR COMMUNITY ACQUIRED PNEUMONIA

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION
OBJECTIVE OF INTERVENTIONS RATIONALE
CARE

Signs and Symptoms Activity intolerance At the end of 8-hour - Provide a quiet - Encourage the After the 8-hour RLE,
presented: related to imbalance RLE, the patient will: environment use of stress 09/05//2022 at 3:15 goals were met as:
between oxygen and limit management PM
OBJECTIVE CUES: supply and demand as - Achieve an visitors during and diversional - Patient
Upon observation, it evidenced by general improved the acute phase activities as 1. Performed achieved an
was noted that: malaise, feeble physical state. as indicated. appropriate. assessment . improved
- The patient appearance, and verbal - Achieve and 2. Checked v/s of physical state
appears feeble. reports of lost energy maintain a - Reduce stress - Reducing stress the newborn, as evidenced
- Has turned Respiratory and excess is imperative to FHR = 92 bpm, by active
pale, was rate of 22-34 stimulation, promote rest RR = 20 participation in
perspiring, and breaths/min promoting rest and healing. breaths/min, activities
had lost his and pulse rate SpO2= 91 %, initiated by
energy. of 80-120 bpm. . all the rest are parent and
- Explain the - Bedrest is within normal attending
Vital Signs: importance of maintained values. physician.
- PR: 60 bpm rest in the during the 3. Assessed - Patient’s
- RR: 48 treatment plan acute phase to patient's respiratory rate
breaths/min and the decrease appearance and is at 33
necessity of metabolic noted cyanosis breaths/min
balancing rest demands, thus in extremities and pulse rate
activities. conserving while is at 118 bpm.
energy for observing
healing. reflexes,
Activity activity, and
restrictions responses to
thereafter are stimuli.
 determined by 4. Assessed
individual patient’s
patient respiration
response to from time to
activity and time, noting
resolution of rate, depth, and
- Pace activity respiratory use of effort.
for patients insufficiency. 5. Auscultated
with reduced - Effective lungs,
activity. coughing may revealing no
exhaust an sign of
already adventitious
compromised breath sounds.
patient. Fatigue
may be a At 10:00 AM
contributing
factor to 6. Administered
- Assist patient ineffective supplemental
to assume a coughing. oxygen via
comfortable - The patient nasal cannula
position for rest may be at 4-6L/min.
and sleep. comfortable 7. Administered
with an prescribed
elevated head medications.
of the bed, 8. Observed
sleeping in a patient’s
chair, or reaction to
leaning forward medication and
- Assist with on an overbed supplemental
self-care table with oxygen.
activities as pillow support. 9. Advised
necessary. - Provide for a mother to allow
progressive newborn to rest
and to limit
increase in visitors as
activities needed.
during the
recovery phase 10:00 AM – 3:00 PM
and demand. 10. Continuously
Minimizes monitored
exhaustion and patient from
helps balance time to time.
oxygen supply 11. Documented on
and demand. patient’s chart.
12. Endorsed
patient to
incoming shift.

08/31/2022 at 8:30
AM

1. Checked v/s of
the newborn,
FHR = 155
bpm, RR = 45
breaths/min,
SpO2= 97 %,
BP = 64/41
mmHg.
2. Assessed
patient's
appearance and
noted pinkish
body and
extremities.
3. Observed
improved
reflexes,
 activity, and
responses to
stimuli.
4. Observed and
noted better
respiration
from time to
time, noting
rate, depth, and
non0labored
breathing.
5. Auscultated
lungs,
revealing no
sign of
adventitious
breath sounds.
6. Continuously
observed
patient for any
alterations in
V/s and for any
untoward signs
and symptoms.
7. Documented
findings and
procedures
done on
patient’s chart.
Reference/s:
Ellis, E. (2019, November 13). Nursing Care Plan for Perinatal Asphyxia. Nursing Care Plan. Retrieved August 30, 2022, from

https://free-nursingcareplan.blogspot.com/2011/07/nursing-care-plan-for-perinatal.html

Taylor, R. (2018, August 6). Birth Asphyxia Nursing Care Management. RNpedia. https://www.rnpedia.com/nursing-notes/maternal-and-child-nursing-notes/birth-asphyxia/

Young, B. (2017, September 29). How Does Nuchal Cord Affect My Baby? Healthline. Retrieved August 30, 2022, from https://www.healthline.com/health/pregnancy/nuchal-cord

Wayne, G. B. (2022, May 7). Impaired Gas Exchange Nursing Care Plan. Nurseslabs. Retrieved August 31, 2022, from https://nurseslabs.com/impaired-gas-exchange/