SYSTEMS PLUS COLLEGE FOUNDATION
MacArthur Highway, Balibago, Angeles City
COLLEGE OF NURSING
JOURNAL REPORT
In
Intensive Care Unit
(Institution/ Area)
In partial Fulfilment of the Requirements
In the Nursing Care Management 112 – RLE
Submitted by:
Leanne Princess B. Gamboa
Submitted to:
Aristotle M. Parico, MAN, RN
Clinical Instructor
(10-07-2021)
Oxygenation (Pneumonia)
I. Introduction
- Sufficient oxygenation is vital to maintain life. When prioritizing nursing interventions, we often refer to using the
“ABCs,” an acronym used to signify the importance of maintaining a patient’s airway, breathing, and circulation.
Several body systems work collaboratively during the oxygenation process to take in oxygen from the air, carry it
through the bloodstream, and adequately oxygenate tissues. It is important that all parts of the system work
together to ensure that oxygen is delivered appropriately to tissues within each system. Any alteration in these
systems can have catastrophic implications on a patient’s health. First, the airway must be open and clear. The
chest and lungs must mechanically move air in and out of the lungs. The bronchial airways must be open so that
air can reach the alveoli, where the exchange of oxygen and carbon dioxide occurs. The heart must effectively
pump oxygenated blood from the lungs and through the systemic arteries. There must be adequate amounts of
hemoglobin in the blood to sufficiently carry the oxygen molecules to the tissues. However, several medical
conditions such as asthma, chronic obstructive pulmonary disease (COPD), pneumonia, heart disease, and anemia
can impair the body’s ability to effectively complete this oxygenation process.
II. Disease process
A. Simple anatomy
B. Pathophysiology
Pneumonia is an infection that inflames the alveoli, or small air sacs in the lungs, as well as the
surrounding tissue. The purulent material (fluid or pus) fills the inflamed alveoli, impairing their ability to exchange
gases with the surrounding capillaries. Any pathogenic organism, bacteria, or fungus that makes its way into the
alveoli is likely to be very hostile, inflaming and filling them with fluid. The lungs' ability to exchange oxygen and
carbon dioxide is hampered when these fluids accumulate. In response to the inflammation and fluid build-up the
patient will experience:
Falling oxygen levels
Rising carbon dioxide levels
Increased respiratory rate
Increased heart rate
Coughing
Phlegm
Fever
Labored breathing
Vital organs being deprived of oxygen
The first picture below depicts a normal, unobstructed gas exchange. In the second picture, the alveoli have an
accumulation of fluid in them which impairs the gas exchange that occurs with the capillaries and provides
appropriate oxygenation into circulation.
III. Management laboratories, diagnostics, medications
A. General laboratory tests may include: CBC (complete blood count)—evaluates the type and number of
white blood cells; results may indicate that an infection is present. BMP (basic metabolic panel)—blood
tests for sodium, potassium, and other chemistries to help determine the severity of the illness. A chest
X-ray is often used to diagnose pneumonia. Blood tests, such as a complete blood count (CBC) to see
whether your immune system is fighting an infection. Pulse oximetry to measure how much oxygen is in
your blood. Pneumonia can keep your lungs from moving enough oxygen into your blood.Bacterial
pneumonia is frequently treated with antibiotics, which work by stopping the growth of bacteria.
Antibiotics can be taken orally or given intravenously by a healthcare professional. Commonly prescribed
antibiotics include Cipro, Levaquin, and Oracea. Some side effects associated with antibiotics include
diarrhea, nerve damage, and allergic reaction.
Doctors will sometimes recommend cough suppressants and fever reducers to help treat pneumonia
symptoms. Analgesic pain relievers like ibuprofen and acetaminophen can be purchased
over-the-counter. Some cough medicines can be purchased OTC as well, but if the cough is bad enough, a
cough suppressant like codeine might be necessary.
Viral pneumonia, or pneumonia caused by a fungus, may require the prescription of antiviral and
antifungal medications. Relenza (zanamivir) is one example of a popular antiviral, and fluconazole is
commonly prescribed as an antifungal.
Assessment Diagnosis Planning Intervention Rationale Expected
outcome
S: Ineffective airway At the end of the Assess Changes in the After receiving
clearance due to care plan, px respiratory rate, respiratory rate the interventions
- Experienced pneumonia as should: depth, and and rhythm may the px was/has:
fever 2 days ago evidenced by -Be able to rhythm. indicate an early -able to maintain
- “Cant lie down increased sputum maintain clear, sign of impending clear, open
to sleep because i production open airways, as respiratory airways, as
can't stop occurring with evidenced by distress. evidenced by
coughing” as infection. normal breath, normal breath,
verbalized by the normal rate and normal rate and
patient. depth of Cyanosis depth of
respirations, and indicates low respirations, and
O: ability to Assess for color oxygenation and ability to
-Productive effectively cough changes in the that breathing is effectively cough
cough secretions after buccal mucosa, ineffective to secretions after
-Shaking chills treatment and lips, and nail maintain treatment and
-Diagnosed w deep breathing. beds. adequate tissue deep breathing.
CAP oxygenation.
-Will display -display patent
patent airway Wheezes suggest airway with
with breath partial breath sounds
sounds clearing obstruction or clearing and
and absence of resistance. While absence of
dyspnea and Auscultate lungs rhonchi may dyspnea and
cyanosis. for adventitious indicate retained cyanosis.
breath sounds secretions in the
-Will (wheezes and lungs. -Demonstrate
demonstrate rhonchi). improved
improved ventilation and
ventilation and Provides oxygenation of
oxygenation of information on tissues by ABGs
tissues by ABGs the fluid balance within client’s
within client’s of the patient. acceptable range
acceptable range Monitor and Dehydration can and absence of
and absence of record intake and contribute in symptoms of
symptoms of output (I&O) viscous respiratory
respiratory adequately. secretions and distress.
distress. may result to
decrease airway
clearance.
Increased BP, RR,
Assess the and HR occur
client’s vital signs during the initial
as needed while hypoxia and
in distress. hypercapnia. And
when it becomes
severe, BP and
HR drops and
respiratory
failure may
result.
These will
Administer allow/help the px
medications, as to clear mucus
indicated, for from his airways
example thus, allowing the
mucolytics, px to breath
expectorants, better.
bronchodilator
and analgesics.
Assessment Diagnosis Planning Intervention Rationale Expected
outcome
S: Acute pain After 12 hours of Monitor vital Changes in heart Goal met. Patient
Px reports chest related to caring for the signs rate or BP may verbalize a
pain and pneumonia as patient, she will indicate that reduction in chest
headache evidenced by be able to: patient is pain, rated 2/10.
persistent experiencing Px demonstrated
O: coughing. -Patient will pain, especially relaxed manner
Restlessness verbalize relief/ when other as evidenced by a
Irritability control of pain at reasons for calm demeanor
Tachycardia levels less than 3 changes in vital and cooperative
Increased blood to 4 using a signs have been behavior.
pressure rating scale of ruled out.
10/10. Administer
antitussives as These
-Patient will indicated. Do not medications may
demonstrate suppress a be used to
relaxed manner, productive cough; suppress
resting/sleeping moderate non-productive
and engaging in amounts of coughs or reduce
activity analgesics are excess mucus,
appropriately. used to relieve thereby
pleuritic pain. enhancing
-Patient will have general comfort.
a verbalized
understanding of Chest pain,
nonpharmacologi usually present
cal interventions with pneumonia,
for pain relief. may also herald
- Assess pain the onset of
characteristics: complications of
sharp, constant, pneumonia, such
stabbing. as pericarditis
Investigate and endocarditis.
changes in
character,
location, or
intensity of pain.
Assess reports of
pain with Non-analgesic
breathing or measures
coughing. administered
with a gentle
touch can lessen
. Provide comfort discomfort and
measures: back augment the
rubs, position therapeutic
changes, quiet effects of
music, massage. analgesics.
Encourage the Patient
use of relaxation involvement in
and/or breathing pain control
exercises. measures
promotes
independence and
enhances the
sense of
well-being.
Assessment Diagnosis Planning Intervention Rationale Expected
outcome
S: Impaired gas Within8 hours of Observe the color As oxygenation At the end of
exchange related rendering care of skin, mucous and perfusion nursing
to pneumonia as the patient will: membranes, and become impaired, intervention the
evidenced by nail beds, noting peripheral tissues goal was met as
O: inflammation of -Patient will the presence of become cyanotic. evidenced by:
Use of accessory airways and demonstrate peripheral Cyanosis of nail
muscles when alveoli improved cyanosis (nail beds may -Patient’ s
breathing ventilation and beds) or central represent participation in
oxygenation of cyanosis vasoconstriction actions to
-Crackles on tissues by ABGs (circumoral). or the body’s maximize
lower lobe of the within patient’s response to oxygenation.Patie
lungs acceptable range fever/chills; nt demonstrated
and absence of however, improved
-Tachypnic: 58 symptoms of cyanosis of ventilation and
breaths per respiratory earlobes, mucous oxygenation of
minute distress. membranes, and tissues by ABGs
skin around the within patient’s
-Mouth breather -Patient will mouth (“warm acceptable range
maintain optimal membranes”) is and absence of
gas exchange. indicative of symptoms of
systemic respiratory
-Patient will hypoxemia. distress and
participate in maintained
actions to optimal gas
maximize Tachycardia is exchange.
oxygenation. Monitor heart usually present
rate and rhythm, due to fever
and blood and/or
pressure. dehydration but
may represent a
response to
hypoxemia—initi
al hypoxia and
hypercapnia
increase BP and
HR. As hypoxia
becomes more
severe, BP may
drop while HR
tends to be rapid
with
dysrhythmias.
It follows the
progress of the
disease process
and facilitates
alterations in
pulmonary
therapy. Pulse
oximetry detects
changes in
Monitor ABGs, oxygenation. O2
pulse oximetry. sats should be at
90% or greater.
