Beatrice Angeline S.

Marcelo
BSN 4B

Nursing Care Plan on Community Acquired Pneumonia

Date & Assessment Need Nursing Diagnosis with Planning Nursing Interventions with Evaluation
Time Rationale Rationale

11/09/23 Subjective: A Impaired gas exchange After 1 hour of Independent Interventions November 09,
@ 6:00 “Lipong daw C related to Inflammation nursing 2023
PM siya ma’am ug T of airways and fluid-filledinterventions, the 1. Assess respiratory rate, depth, @ 7:00 PM
maglisod ug I alveoli as evidenced by patient will be able and effort, including the use of
ginhawa,” as V low O2 saturation to: accessory muscles, nasal “GOAL MET ”
verbalized by I flaring, and abnormal
the watcher. T Rationale: 1. Demonstrate breathing patterns. After an hour of
Y Pneumonia causes the improved R: Rapid and shallow breathing nursing
Objective: alveoli in one or both ventilation and patterns and hypoventilation interventions, the
● Vital Signs A lungs to become adequate affect gas exchange. Increased patient was able
(11/09/23 N inflamed and filled with oxygenation of respiratory rate, use of accessory to:
@ 6PM) D pus and fluids (exudate), tissues to be muscles, nasal flaring, and
O2 which interferes with the evidenced by abdominal breathing may be 1. Demonstrate
saturation - E gas exchange improved seen with hypoxia. improved
87% X (Pneumonia - Better oxygen ventilation and
T - 36.7 E Health Channel, n.d.). saturation; 2. Elevate the head of the bed adequate
PR - 80 R and position the patient oxygenation
bpm C Reference: 2. Maintain vital appropriately. of tissues as
RR - 16 I Pneumonia - Better signs within R: These measures promote evidenced by
bpm S Health Channel. (n.d.). normal range; maximum chest expansion, oxygen
BP - E https://www.betterhealth. mobilize secretions and improve saturation of
110/90 vic.gov.au/health/conditio 3. Exhibit no signs ventilation (Vera, 2022). 95%
● Pale skin P nsand of respiratory
and nails A treatments/pneumonia distress. 3. Limit activities to within the 2. Vital signs as
● Uses T patient's tolerance. follows:
accessory T R: This helps limit oxygen needs
muscles E and consumption (Aprn Bc et al., T - 36.8 C
when R 2019). PR - 79 bpm
breathing, N RR - 15 bpm
specifically 4. Keep environment allergen BP - 120/80
the (O and pollutant free. mmHg
sternocleid X R: To reduce the irritant effect of
omastoid Y dust and chemicals on airways 3. Exhibited no
and G (Aprn Bc et al., 2019). signs of
external E respiratory
intercostal N) 5. Monitor pulse oximetry q4h or distress.
muscles as frequently as ordered.
R: Pulse oximetry detects
changes in oxygenation. O2 sats
should be at 90% or greater Prepared by:
(Vera, 2022).
BEATRICE ANGELINE
S. MARCELO
6. Monitor vital signs and cardiac AdDU SN
rhythm.
R: All vital signs are impacted by
changes in oxygenation (Aprn Bc
et al., 2019).

Dependent Interventions
7. Administer oxygen therapy as
ordered.
R: The purpose of oxygen
therapy is to maintain PaO2
above 60 mmHg (Vera, 2022).

8. Administer medications, as
 ordered.
R: Pharmacological agents are
varied, specific to the patient, but
generally used to prevent and
control symptoms, reduce
frequency and severity of
exacerbations, and improve
exercise tolerance (Aprn Bc et
al., 2019).

9. Provide airway adjuncts and

suction, as indicated
R: to clear or maintain open
airway, when patient is unable to
clear secretions, or to improve
gas diffusion when patient is
showing desaturation of oxygen
by oximetry or ABGs (Aprn Bc et
al., 2019).

10. If the patient is unable to

cough, use nasotracheal
suctioning as needed.
R: Suctioning is indicated when
patients are unable to remove
secretions from the airways by
coughing because of weakness,
thick mucus plugs, or excessive
or tenacious mucus production
(Aprn Bc et al., 2019).