Monday, May 18, 2009

Nursing care plan for Pneumonia

“I have rapid, labored respirations", as verbalized by the patient.
“I feel restless and weak", as verbalized by the patient.
Temp. 39.2 degrees Celsius
Pulse rate: 70 BPM
Respiration: 24 breaths/min.
BP: 118/70 mm Hg
inspiratory crackles with diminished/adventitious breath sounds right base; excessive sputum production; skin pale; cheeks flushed; chills; use of accessory muscles
Nursing Diagnosis
Ineffective airway clearance related to inability to maintain clear airway as characterized by (+) sputum (+) crackles, rapid, labored respiration, pallor and use of accessory muscles when breathing.


Client will:
Maintain airway patency
expectorate/clear secretions readily
Demonstrate absence/reduction of congestion with breath sounds clear, respirations noiseless, improve oxygen exchange *Encourage deep breathing and coughing exercises


* Encourage use of incentive spirometry, a appropriate

*Increase fluid intake to at least 2000ml/day within cardiac tolerance

*Administer analgesics

*Monitor respirations and breathe sounds, noting rate, rhythm and effort.

*Note chest movement, watching for symmetry, use of accessory muscles, and supraclavicular and intercostals muscle refractions

*Evaluate cough/gag reflex and swallowing ability

*Auscultate breath sounds and assess air movement to ascertain status and note progress
*Observe signs of respiratory distress(increased rate, restlessness/anxiety, use of accessory muscles for breathing)
*Obtain sputum specimen, preferably before antimicrobial therapy is initiated
*Institute respiratory therapy treatments as needed

*monitor/document serial chest X-rays and changes in tidal volume and ABG values


*Deep breathing promotes oxygenation before controlled coughing

*Breathing exercises help maximize ventilation

*Assist to a sitting position with head slightly flexed, shoulders relaxed, and knees flexed

*It improves cough when pain is inhibiting effort

*Provides a basis for evaluating adequacy of ventilation and indicates of respiratory distress and/or accumulation of secretions.

*Presence of nasal flaring and use of accessory muscles of respiration may occur in response to ineffective ventilation

* Determines ability to protect own airway

* Assists in evaluating prescribed treatments and client outcomes

*These clinical manifestation would be early indicators of hypoxia

*Verifies appropriateness of therapy

*A variety of respiratory therapy treatments may be used to open constricted airways and liquefy secretions

*Evaluates the status of oxygenation, ventilation and acid-base balance

Outcome met. The patient maintains airway patency. Expectorated/cleared secretions readily. Demonstrated reduction of congestion with breath sounds clear, respirations noiseless, and improved oxygen exchange

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