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Community Acquired Pneumonia Nursing Care Plan: Demonstrate Pursed-Lip and Diaphragmatic Breathing To The Patient

The nursing care plan is for a patient diagnosed with community acquired pneumonia. The plan includes assessments, diagnosis, planning, interventions, and evaluation. The diagnosis is impaired gas exchange related to changes in the alveolar-capillary membrane as evidenced by confusion, dyspnea, abnormal lung sounds, and abnormal blood gases. The plan is to improve ventilation and oxygenation through nursing interventions over 6 hours. Interventions include positioning, breathing exercises, monitoring, medications, IV fluids and health teaching. The evaluation after 6 hours found improved blood gases and decreased respiratory rate and heart rate, though some abnormal lung sounds remained. The goal was partially met.

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Krisianne Mae Lorenzo Francisco
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18K views4 pages

Community Acquired Pneumonia Nursing Care Plan: Demonstrate Pursed-Lip and Diaphragmatic Breathing To The Patient

The nursing care plan is for a patient diagnosed with community acquired pneumonia. The plan includes assessments, diagnosis, planning, interventions, and evaluation. The diagnosis is impaired gas exchange related to changes in the alveolar-capillary membrane as evidenced by confusion, dyspnea, abnormal lung sounds, and abnormal blood gases. The plan is to improve ventilation and oxygenation through nursing interventions over 6 hours. Interventions include positioning, breathing exercises, monitoring, medications, IV fluids and health teaching. The evaluation after 6 hours found improved blood gases and decreased respiratory rate and heart rate, though some abnormal lung sounds remained. The goal was partially met.

Uploaded by

Krisianne Mae Lorenzo Francisco
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Francisco, Krisianne Mae L.

BSN III B (group B3)

Community Acquired Pneumonia Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective DEPENDENT
“masama ang pakiramdam Impaired gas exchange After 6hrs of nursing  Observe the use of  For personal  After 6 hrs of
ko. Sumasakit itong related to alveolar – intervention the patient will PPE. protection against nursing intervention
katawan ko at nahihirapan capillary membrane verbalize improved the infection. the patient’s ABGs
din akong huminga dahil changes as characterized by ventilation such as normal parameter were
ditto sa ubo ko” confusion, dyspnea, range of cardiac and  Place patients who are  To improve lung improved, and the
Objective abnormal lung sounds, respiratory rate, adequate experiencing dyspnea expansion. patient’s cardiac rate
 Confused cyanosis, and abnormal oxygenation of tissues by in a high Fowler and respiratory rate
 Central cyanosis ABGs. ABGs within patient’s position. decreased into
 Dry cough normal parameters, and the normal rate but
 Widespread bilateral absence of abnormal lung  Demonstrate pursed-lip  Provides patient ronchi and crackles
crackles and rhonchi sounds. and diaphragmatic with some means to in both lungs were
 Diffusely tender breathing to the cope with or control still audible. Goal
abdomen patient. dyspnea and reduce partially met.
 Diarrhea air-trapping.
 Dehydrated and
flushed (poor skin
turgor)  To evaluate the
 Rigors/ sudden  Monitor patient’s vital patient’s health
feeling of cold and signs. reaction from
shivering medical and nursing
 Temperature 39.5⁰C intervention
 RR 32 bpm
(tachypneic)
 PR 120 bpm  To manage
(tachycardic)  Provide tepid sponge hyperthermia.
 Hypoxemia – PO2 bath.
6.3 kPa
 Hypocapnia – PCO2
2.7 kpa
 X – ray shows
atypical pneumonia
 With IVF PLRS INDEPENDENT
400cc regulated at
41-42 gtts/min
inserted at right  Provide airway suction  To clear secretions
peripheral cephalic as indication. or maintain open
vein. airway and to
improve gas
diffusion when
client is showing
desaturation of
oxygen by ABGs.

 Provide supplemental  To increase oxygen


oxygen as indicated. level.

 Administer medication  For the medical


as indicated. management of
CAP.
 Cefuroxime 750 mg IV
every 8 hours for 5
days 

 Clarithromycin 500 mg
IV q 12 hours for 3
days. 
 Paracetamol 100mg IV
q 4 hours.

 Maintain IVF Solution:  To treat


PLRS 1L to run for 6 dehydration.
hours as ordered by the
doctor.

COLLABORATIVE

 Encourage to keep  To reduce irritant


environment allergen effect of dust and
and pollutant free. chemicals on
airway.

 Encourage to perform
regular and  For appropriate
demonstrate proper infection control
hand hygiene such as procedure.
washing hands with
soap and the use of
alcohol – based
sanitizer.

 Encourage adequate
fluid intake but avoid  Fluid intake for
fluid overload mobilization of
secretions and fluid
overload to prevent
pulmonary
congestions.
 Advise the patient to
maintain high protein  High protein diet
diet such as eating can boost
meat, fish, eggs, beans, metabolism and
dairy product and some immune system to
foods rich in proteins. fight against
infection.
 Reinforce the need for
adequate rest while  To decrease dyspnea
encouraging activity and improve quality
such as light exercise of life.
and short walks.

 Encourage client and


significant others to  To reduce health
stop smoking and risk and prevent
avoid second-hand further decline in
smoke. lung function.

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