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Student Nurses Community

NURSING CARE PLAN Pneumonia


Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

Subjective: Ineffective Ariway Bacterial/ Viral Short term goal: Independent:


Nahihirapan akong Clearance related to Invasion Deep breathing After 8 hours of
humingi (Its difficult the increased After 8 hours of Encourage deep promotes nursing
to breathe) as production of nursing breathing oxygenation intervention, goal
verbalized by the respiratory secretions intervention, exercises before controlled partially met.
patient. secretions will be Assist patient in coughing The patient was
Multiplication of mobilized, airway coughing To improve able to >
Objective: bacteria /virus; patency will be exercises productivity of demonstrate
Rapid breathing/ enters the luns maintained free of Increase fluid the cough. coughing and
tachypnea secretions, as intake, as Adequate fluid deep breathing
Cough with yellow evidenced patients appropriate intake enhances exercise every 1-2
sputum production ability to effectively Monitor rate, liquefaction of hours during the
Diminished and Cells of the immune cough out rhythm, depth, pulmonary day
adventitious breath system gathers in secretions, clear and effort of secretions and
sounds (crackles) lungs to stop lung sounds, and respirations. facilitates > Clients
Dyspnea infection uncompromised Assist patient expectoration of respiratory rate is
VS taken as respiratory rate. into moderate mucus. within normal
follows: high back rest Provides a basis range (RR 19)
position for evaluating
T 36.9 C Auscultate lung adequacy of > Inspiratory
P 89 bpm fields, noting ventilation crackles can still
RR 36 br/min
Inflammation & areas of To promote be heard at the
BP 130/80 mmHg
production of decreased of drainage of right lower lobe
secretions increase absent airflow secretions and
and adventitious better lung > cough
breath sounds expansion continues to be
Student Nurses Community
Decreased airflow productive.
Pulmonary infection occurs in areas
Dependent: consolidated with
Administer fluid. Bronchial
sputum production; ordered breath sounds
excess, medications (normal over
accumulated such as bronchus) can
secretion in the mucolytic also occur in
airways agents, consolidated
bronchodilators, areas. Crackles,
expectorants rhonchi, and
Administer wheezes are
airway blockage nebulizations as heard on
needed inspiration and/or
expiration in
response to fluid
accumulation,
thick secretions,
and airway
spasm/obstructio
n.
To help loosen
and clear the
mucus from the
airways
(mucolytics);
decrease
resistance in the
respiratory airway
and increase
airflow to the
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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

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