Lopez, Maria Sofia B.

10/07/2020

3-BSN-B Prof. Zoleta

NURSING CARE PLAN: PNEUMONIA

NURSING PLANNING
ASSESSMENT DIAGNOSIS GOAL / NURSING RATIONALE EVALUATION
EXPECTED INTERVENTIO
OUTCOME NS
Subjective: •Ineffective After a series - Assessed vital -to assist in After a series
-emphysema for airway of nursing signs, creating an of nursing
25 years clearance intervention, respirations, accurate intervention,
-h/o smoking related to the patient and breath diagnosis and the patient was
-increased increased will be able to sounds, noting monitor able to
dyspnea production of demonstrate rate and effectiveness demonstrate
secretion as behaviors to sounds. of medical behaviors to
Objective: evidenced by improve or treatment improve or
-sputum sputum maintain maintain clear
production production, clear airway. -Positioned -to open or airway.
-presence of increased head maintain
barrel chest dyspnea, and appropriately for open airway
presence of age and in at rest or
barrel chest. condition compromised
individual

-Elevated head -To take

of bed and advantage of
change position gravity
every 2 hours decreasing
and prn pressure on
the
diaphragm
and
enhancing
drainage
of/ventilation
to different
lung
segments.

-Encouraged -Provides
abdominal or patient with
pursed-lip some means
breathing to cope with
exercises. or control
dyspnea and
 reduce air-
trapping.

-Increased fluid -Hydration

intake to 3000 helps
mL per day decrease the
within cardiac viscosity of
tolerance. secretions,
Provide warm facilitating
or tepid liquids. expectoration
Recommend . Using warm
the intake of liquids may
fluids between, decrease
instead of bronchospas
during, meals. m. Fluids
during meals
can increase
gastric
distension
and pressure
on the
diaphragm.

-Administered -More
bronchodilators aggressive
if prescribed. measures to
maintain
airway
patency.
 NURSING PLANNING
ASSESSMENT DIAGNOSIS GOAL / NURSING RATIONALE EVALUATION
EXPECTED INTERVENTIO
OUTCOME NS
Subjective: • Ineffective After a series -Determined -that would After a series
-emphysema for breathing of nursing presence of cause of nursing
25 years pattern intervention, factors/physical breathing intervention,
-h/o smoking related to the patient conditions as impairments the patient was
-increased chest wall will be able to noted able to
dyspnea deformity as establish an establish an
evidenced by improvement -Auscultated -to evaluate improvement of
Objective: barrel chest. of breathing chest. presence/cha breathing
-sputum pattern. racter of pattern.
production breath
-presence of sounds and
barrel chest secretions

- Placed a pillow -Place a

when the client pillow when
is sleeping. the client is
sleeping.

- Instructed how - Promotes

to splint the physiological
chest wall with a ease of
pillow for maximal
comfort during inspiration.
coughing and
elevation of
head over the
body as
appropriate.

- Provided - Aid in
respiratory relieving the
support. Oxygen patient from
inhalation is dyspnea.
given as
ordered.

- Administered -to promote

with analgesics, deeper
as appropriate, respiration
as prescribed. and cough
 NURSING PLANNING
ASSESSMENT DIAGNOSIS GOAL / NURSING RATIONALE EVALUATION
EXPECTED INTERVENTIO
OUTCOME NS
Subjective: • Impaired After a series -Assessed and -Useful in After a series
-emphysema for gas of nursing recorded evaluating the of nursing
25 years exchange intervention, respiratory rate, degree of intervention,
-h/o smoking related to the patient depth. Note the respiratory the patient was
-increased alveoli will be able to use of distress or able to
dyspnea destruction demonstrate accessory chronicity of demonstrate
as evidenced improved muscles, the disease improved
Objective: by h/o of ventilation pursed-lip process. ventilation and
-sputum emphysema and breathing, adequate
production for 25 years, adequate inability to oxygenation of
-presence of increased oxygenation speak or tissues by
barrel chest dyspnea and of tissues by converse. ABGs within
presence of ABGs within patient’s
barrel chest. patient’s -Monitored vital -Tachycardia, normal range.
normal signs and dysrhythmias,
range. cardiac rhythm. and changes
in BP can
reflect the
effect of
systemic
hypoxemia on
cardiac
function.

-Auscultated -Breath
breath sounds, sounds may
noting areas of be faint
decreased because of
airflow and decreased
adventitious airflow or
sounds. areas of
consolidation.
Presence of
wheezes may
indicate
bronchospas
m or retained
secretions.
Scattered
moist crackles
may indicate
interstitial fluid
or cardiac
decompensati
on.
-Elevated the -Oxygen
head of the delivery may
bed, assist the be improved
patient to by upright
assume a position and
position to ease breathing
work of exercises to
breathing. decrease
airway
collapse,
dyspnea, and
work of
breathing.
Use of prone
position to
increase
Pao2.

-Provided -Administering
humidified humidified
oxygen as oxygen
ordered. prevents
drying out the
airways,
decrease
convective
moisture
losses, and
improves
compliance.
 NURSING PLANNING
ASSESSMENT DIAGNOSIS GOAL / NURSING RATIONALE EVALUATION
EXPECTED INTERVENTIO
OUTCOME NS
Objective: • Disturbed After a series -Determined -There is After a series
-presence of body image of nursing whether always of nursing
barrel chest related to intervention, condition is something intervention,
alteration of the patient permanent with that can be the patient was
body will be able to no expectation done to able to
structure as verbalize for resolution. enhance verbalize
evidenced by understandin acceptance understanding
presence of g of body and it is of body
barrel chest changes. important to changes.
hold out the
possibility of
living a good
life with
disability.

-Evaluated -may indicate

level of client’s acceptance or
knowledge of nonacceptanc
and anxiety e of situation
level related to
situation.

-Established -to convey an

therapeutic attitude of
nurse-client caring and
relationship developing a
sense of trust

-Assisted in -to promote

correcting optimal
underlying healing and
problems adaptation

-Encouraged -to enhance

verbalization of handling of
conflicts potential
situations
 NURSING PLANNING
ASSESSMENT DIAGNOSIS GOAL / NURSING RATIONALE EVALUATION
EXPECTED INTERVENTIO
OUTCOME NS
• Risk for After a series -Reviewed the -These After a series
infection of nursing importance of activities of nursing
intervention, breathing promote intervention,
the patient exercises, mobilization the patient was
will be able to effective cough, and able to
demonstrate frequent expectoration demonstrate
techniques, position of secretions techniques,
lifestyle changes, and to reduce the lifestyle
changes to adequate fluid risk of changes to
promote safe intake. developing a promote safe
environment. pulmonary environment.
infection.

-Observed -Odorous,
color, yellow, or
character, odor greenish
of sputum secretions
suggest the
presence of
pulmonary
infection.

-Demonstrated -Prevents
and assisted spread of
the patient in fluid-borne
the disposal of pathogens.
tissues and
sputum. Stress
proper
handwashing
(nurse and
patient), and
use gloves
when handling
or disposing of
tissues, sputum
containers.

-Encouraged a -Reduces
balance oxygen
between consumption
activity and or demand
rest. imbalance,
and improves
patient’s
resistance to
infection,
promoting
healing.
- -to determine
Administered/m effectiveness
onitored of therapy or
medication presence of
regimen side effects