William Carey University

School of Nursing
Care plan
Priority: Student Name: Jennifer Gomila Date of Care: 0!0!"0#$
%ssessment data
&'()ective and Su()ective*
Nursing Diagnosis and
+,pected outcomes

-mplementation!-nterventions

Scientific .ationale

+valuation
Diagnosed with pneumonia and
Acute Bronchitis
Subjective:
c/o SOB & Dyspnea
Objective:
Clients dependence on
supplemental o!ygen
"#/min/nasal cannula$
Albuterol/%pratropium
"&'mg/(m#$
)achypnea$
*ypo!emia$
+&, *bg g/d#$
"+&(- *C)
Con.usion$
#ymphocytes "/&'-$
0onocytes 1/&1-$
Albumin "&2$
%mpaired 3as 4!change related
to ventilation5per.usion
ine6uality as evidenced by SOB$
dyspnea$ Clients dependence
on supplemental o!ygen
"#/min/nasal cannula$
Albuterol/%pratropium
"&'mg/(m#$
)achypnea$
*ypo!emia$
+&, *bg g/d#$
"+&(- *C)
Con.usion$
#ymphocytes "/&'-$
0onocytes 1/&1-$
Albumin "&2$ secondary to
pneumonia&
77777777777777777777
Desired Outcome
1& 8atient will maintain optimal
gas e!change$ as evidenced by
o!ygen saturation o. +" - or
greater during 1" hour shi.t
"& 9entilation will not be
compromised as evidenced by
maintaining respiratory rate
within normal range o. 1" : "/
breaths per minute during 1"
hour shi.t
(& 8atient will have decreased
SOB as evidenced by not using
accessory muscle to breathe
and maintaining heart rate
within normal range o. ;/ : 1//
beats per minute during #"
hour shift
1& 0onitor O" saturation 6,h with
pulse o!imetry and veri.y that
supplemental o!ygen delivery
system is properly in place
"& Assess respiratory rate and
e..ort 6,h&
(& Assess heart rate /$h0
,& 0aintain o!ygen administration
device as ordered$ "/#/<C$
attempting to maintain o!ygen
saturation at +"- or greater
'& )each and encourage slow$ deep
breath as appropriate&
;& 8osition patient .or optimal
breathing patterns including high
.owlers position 6"h&
1& 8ulse o!imetry is use.ul to
detect changes in o!ygenation&
O!ygen saturation should be
maintained at +"- or greater&
"& =ith initial hypo!ia
respiratory rate rises& As the
hypo!ia becomes more severe
respiratory .ailure may ensue
when the patient is unable to
maintain the rapid respiratory
rate&
(& =ith initial hypo!ia heart
rate rises& As the hypo!ia
becomes more severe heart
rate will drop and dysrhythmias
may occur&
,& Supplemental o!ygen may
be re6uired at an acceptable
level&
'& Slow$ deep breathing
reduces tachypnea and
alveolar collapse&
;& >pright position allows .or
increased thoracic capacity and
.ull descent o. diaphragm&
Patient maintained a
minimal o,ygen
saturation of 123
during my shift0
%ll goals met0
Dyspnea$ tachypnea$ and
orthopnea
8t& complaint o. chest pain
8t& complaint o. sob and
wea?ness with ambulation&
%ne..ective Breathing 8attern
@/) %nade6uate chest e!pansion
due to .atigue or blunting o.
respiratory drive$ in.lammatory
process$
A4B Dyspnea$ tachypnea$ and
orthopnea secondary to
pneumonia and acute
bronchitis&
Desired outcomes:
1&=ill maintain an e..ective
breathing pattern as evidenced
by maintaining a respiration rate
between 1" : "/ bpm 1" hour
shi.t
"& =ill maintain an e..ective
breathing pattern as evidenced
by absence o. dyspnea 1" hour
shi.t
($ =ill have an increased ability
to clear respiratory secretions
immediately
1& Assess ability to clear secretions
6,h&
"& Assess respiratory rate$ rhythm$
and depth /$h0
(& 4ncourage sustained deep
breaths by:
>sing demonstration AemphasiBing
slow inhalation$ holding end
inspiration .or a .ew seconds$
passive e!halation$ and pursed5lip
breathingC&
,& 0onitor .or changes in level o.
consciousness evidenced by
slurred speech$ altered mental
status$ e!cess lethargy 6,h during
shi.t&
'& 8rovide reassurance and allay
an!iety by staying with the patient
during acute episodes o. respiratory
distress&
;&Administer one tab o. 4!"4
*ydrocodone/Acetaminophen as
prescribed 8@< to relieve pain.ul
cough
1& An obstructed airway may
cause a change in breathing
pattern&
"& @espiratory rate and rhythm
changes are early warning
signs o. impending respiratory
di..iculties&
(& )his techni6ue promotes
deep inspiration$ which
increases o!ygenation and
prevents atelectasis&
Controlled breathing
techni6ues may also help slow
respirations in patients who are
tachypneic& 8rolonged
e!piration prevents air trapping&
,& @estlessness$ con.usion$
and/or irritability can be early
indicators o. insu..icient o!ygen
to the brain& #ethargy and
somnolence are late signs o.
hypo!ia&
'&& )he presence o. a trusted
person may help the patient
.eel less threatened and can
reduce an!iety$ thereby
reducing o!ygen re6uirements&
;& *ydrocodone is both an
analgesic and antitussive used
to suppress cough re.le! and
allow patient to rest and be
relieved o. chest pain
associated with severe cough&
.espiration rate
remained 5ithin
normal limits at #6
(pm
%ncreased sputum production in
response to respiratory in.ection
as evidenced by rhonchi lung
sounds$ ine..ective cough$
purulent sputum$ dyspnea$
tachypnea and hypo!emia
%ne..ective Airway Clearance
@/) increased sputum
production in response to
respiratory in.ection as
evidenced by rhonchi lung
sounds$ ine..ective cough$
purulent sputum$ dyspnea$
tachypnea and hypo!emia
secondary to pneumonia&
Desired outcomes:
1& =ill maintain patent airway
during SN shift and decreased
respiratory secretions 5ithin $
hours of shift start0
"& =ill have decreased viscous
mucus secretions resulting
increased ability to e!pectorate
within $ hours of shift start&
(& =ill be able to demonstrate
ability to e..ectively e!pectorate
secretions and maintain patent
airway clearance by deep
breathing e!ercises
immediately after teaching&
1& 0aintain hydration by providing
and encouraging 12// 5 "1;/ ml
.luid/daily within cardiac tolerance
"& )each patient the signi.icance o.
increased SOB and changes in
sputum$ such as color$ character$
amount$ and odor and to report
changes to their primary health
provider&
(& 8rovide Oral Care in the morning
and a.ter meals
,& Assess cough .or e..ectiveness
and productivity& Observe
characteristics o. sputum: color$
amount$ and odorD report signi.icant
changes when sputum samples are
available during my shift
'& Assess .or the use o. accessory
muscles /$h
1& *ydration helps decrease
the viscosity o. secretions
.acilitating e!pectoration&
"& 3reen$ yellow$ bloody$
malodorous sputum and
increased SOB may indicate
in.ection&
(& Secretions .rom pneumonia
are o.ten .oul tasting and
smelling& 8roviding oral care
may decrease nausea and
vomiting associated with the
taste o. secretions&
,& 8atients may have
ine..ective cough because o.
.atigue or thic? tenacious
secretions& A sign o. in.ection
is discolored sputum& An odor
may be present&
'& )he breathing pattern may
alter to include use o.
accessory muscles to increase
chest e!cursion to .acilitate
e..ective breathing&
Pt0 effectively
practiced deep
pursed lip (reathing
and learned to
cough 5ith deeper
force to e,pectorate
secretions0 %ir5ay
remained patent0