NURSING CARE PLAN

Name of Patient: B.A. Age: 80 y.o Status: Married .

Address: Duero, Bohol Date: 09/18/2019 Ward: Medical 3 Bed No. ICA .
Impression: ACUTE RESPIRATORY FAILURE SECONDARY TO COMMUNITY ACQUIRED PNEUMONIA – HIGH RISK .
PROBLEM RATIONALE DESIRED GOAL BEHAVIORAL NURSING ACTION RATIONALE EVALUATION
CUES/NRSG. DX OBJECT

 IMPAIRED GAS Inspiration or Short term: INDEPENDENT:

EXCHANGE: aspiration of
Alveolar-capillary oral secretions After 8 hours of nursing care and 1. Maintain patent airway. - monitoring the need of timely
membrane changes containing the interventions, the patient will be able suctioning and/or
SECONDARY TO: causative agent to: nasopharyngeal
INFECTION - maintain optimal gas exchange as airway/intubation is essential
evidenced by usual mental status, to ensure adequate oxygen
Objective Cues: Bacteria enters unlabored respirations at 12-20 per delivery.
into the lungs minute, oximetry results within normal
 Upon interview range, blood gases within normal 2. Provide supplemental oxygen as - aides in increasing the
and thorough range, and baseline HR for patient. needed. oxygen levels and maintaining
assessment, the Compromised the oxygen levels needed in the
patient: immune system Long term: body.

- appears to have After 3 days of nursing care and 3. Ensure patient is in optimal - semi/high fowler’s position is
a decreasing her Body interventions, the patient will be able position to decrease breathing needed to enable appropriate
level of compensates to: workload. lung expansion to facilitate
consciousness and employs the -maintain clear lung fields and better gas exchange. (if
mechanism of remains free of signs of respiratory clinically appropriate)
- has pale skin, cough reflex distress.
lips , nail beds and 4. Remove any distracting stimuli: - to relieve/ avoid anxiety and
and etc. development/thi -manifests resolution or absence Turn the TV off, discourage social
ckening of of symptoms of respiratory distress. media access, encourage family
mucous members to be calm.
secretions
-has increased
breathing
workload through Organisms
flaring nostrils invading begin
and exertion to multiply,
releasing toxins
-had her ABG
analysis showing
signs of hypoxia, Inflammation
hypoxemia and and edema of
hypercapnia the lung
parenchyma (the
-has these tissue lining the
following vital air pockets or
signs: sacs of the lungs
called
BP- 120/70 ALVEOLI)
PR- 89 bpm
RR- 20 cpm
T- 37.1 C Fluid
O2 Satutation - accumulates the
Alveoli sacs and
becomes full

WBC’s
increases as the
body’s
compensatory
mechanism
resulting to a
symptom of
 elevated body
temperature

RBC’s are
compromised
causing the
hemoglobin to
decrease its
capacity to carry
out oxygen and
therefore,
carbon dioxide
increases

HYPOXEMIA
(Respiratory
Acidosis)

Alveolar –
capillary
membrane
changes