University:
Chamberlain University
Course:
NR 324 | Adult Health
Academic year:

2019
Views:

132

Pages:

1
Author:

5prinzg1s

Pneumonia Nursing Care Plans ASSESSMENT  Increase in       respiratory rate of 31 cpm Shortness of breath (orthopnea) Dyspnea Use of accessory muscles in breathing Altered chest excursion Nasal Flaring Increased anteriorposterior diameter OBJECTIVES 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 NURSING INTERVENTIONS 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 RATIONALE 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 EXPECTED OUTCOMES 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