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Student Nurses Community

NURSING CARE PLAN Pneumonia


Assessment

Diagnosis

Inference

Planning

Intervention

Subjective:
Nahihirapan akong
humingi (Its difficult
to breathe) as
verbalized by the
patient.

Ineffective Ariway
Clearance related to
the increased
production of
respiratory secretions

Bacterial/ Viral
Invasion

Short term goal:

Independent:

Objective:
Rapid breathing/
tachypnea
Cough with yellow
sputum production
Diminished and
adventitious breath
sounds (crackles)
Dyspnea
VS taken as
follows:
T 36.9 C
P 89 bpm
RR 36 br/min
BP 130/80 mmHg

Multiplication of
bacteria /virus;
enters the luns

Cells of the immune


system gathers in
lungs to stop
infection

Inflammation &
production of
secretions increase

After 8 hours of
nursing
intervention,
secretions will be
mobilized, airway
patency will be
maintained free of
secretions, as
evidenced patients
ability to effectively
cough out
secretions, clear
lung sounds, and
uncompromised
respiratory rate.

Encourage deep
breathing
exercises
Assist patient in
coughing
exercises
Increase fluid
intake, as
appropriate
Monitor rate,
rhythm, depth,
and effort of
respirations.
Assist patient
into moderate
high back rest
position
Auscultate lung
fields, noting
areas of
decreased of
absent airflow
and adventitious
breath sounds

Rationale

Evaluation

Deep breathing
promotes
oxygenation
before controlled
coughing
To improve
productivity of
the cough.
Adequate fluid
intake enhances
liquefaction of
pulmonary
secretions and
facilitates
expectoration of
mucus.
Provides a basis
for evaluating
adequacy of
ventilation
To promote
drainage of
secretions and
better lung
expansion

After 8 hours of
nursing
intervention, goal
partially met.
The patient was
able to >
demonstrate
coughing and
deep breathing
exercise every 1-2
hours during the
day
> Clients
respiratory rate is
within normal
range (RR 19)
> Inspiratory
crackles can still
be heard at the
right lower lobe
> cough
continues to be

Student Nurses Community


Pulmonary infection

sputum production;
excess,
accumulated
secretion in the
airways

airway blockage

Dependent:
Administer
ordered
medications
such as
mucolytic
agents,
bronchodilators,
expectorants
Administer
nebulizations as
needed

Decreased airflow
occurs in areas
consolidated with
fluid. Bronchial
breath sounds
(normal over
bronchus) can
also occur in
consolidated
areas. Crackles,
rhonchi, and
wheezes are
heard on
inspiration and/or
expiration in
response to fluid
accumulation,
thick secretions,
and airway
spasm/obstructio
n.
To help loosen
and clear the
mucus from the
airways
(mucolytics);
decrease
resistance in the
respiratory airway
and increase
airflow to the

productive.

Student Nurses Community


lungs
(bronchodilators)
and to loosen and
clear mucus and
phlegm from the
respiratory tract
(expectorants)
A variety of
respiratory
therapy
treatments may
be used to open
constricted
airways and
liquefy secretions.

Sources:
http://wps.prenhall.com/wps/media/objects/3918/4012970/NursingTools/ch50_NCP_IneffAirClear_1395-1396.pdf

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