Pneumonia Nursing Care Plans

ASSESSMENT OBJECTIVES NURSING

INTERVENTIONS

RATIONALE EXPECTED OUTCOMES

Increase in

respiratory rate of 31 cpm

Shortness of breath (orthopnea)

Dyspnea

Use of accessory

muscles in breathing

Altered chest

excursion

Nasal Flaring

Increased anterior-posterior diameter

SHORT TERMAfter 2-3 hours of nursing intervention, patient will be able to verbalize understanding and demonstrate proper deep

breathing technique to facilitate proper oxygenation to alleviate hyperventilation

LONG TERM

After 2-3 days of nursing intervention, patient will be free of cyanosis and establish normal breathing

pattern

1. Establish rapport with patient

2. Instruct patient to increase oral fluid intake to 8-10 glasses

3. Instruct patient to do deep breathing exercise after demonstrating proper technique

4. Keep environment allergen free (dust, feather pillows, smoke, pollen)

5. Take and VS 6. Suction naso,

tracheal/oral PRN

7. Educate proper hand washing

8. Position the patient in semi fowler’s position

9. Encourage patient to eat nutritious foods such as green leafy vegetables and lean meat

10. Review client’s chest x-ray for severity of

acute/ chronic conditions

1. To gain patient’s trust and cooperation

2. Increased mucus and sputum secretions can lead to

dehydration; increased water intake can help dissolve secretions

3. Deep breathing exercise increases oxygen intake and can help alleviate dyspnea

4. Presence may trigger allergic response that may cause

further increase in mucus secretion

5. To get baseline data 6. These may

compromise airway. A distended abdomen can interfere with normal diaphragm expansion

7. To increase feeling of comfort

8. To enable the body to recuperate and repair

9. To prevent infections such as nosocomial infections

10. To prevent allergic reactions that can cause respiratory distres

SHORT TERMClient shall verbalize understanding and demonstrate proper deep breathing technique to facilitate proper oxygenation to alleviate

hyperventilation

LONGTERM

Patient shall be free of cyanosis and establish normal breathing pattern