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NCP Pneumonia

The document outlines a nursing care plan for a patient with impaired gas exchange related to an inflammatory respiratory condition. It details subjective and objective assessment findings that may be reported by the patient or observed by nurses. These include fatigue, cough, sputum production, decreased breath sounds, and chest pain. The plan involves administering oxygen, proper positioning, mouth care, lung auscultation, and monitoring vital signs and blood gas levels to improve ventilation and gas exchange over 8 hours.

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Christian Apelo Serquillos
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2K views

NCP Pneumonia

The document outlines a nursing care plan for a patient with impaired gas exchange related to an inflammatory respiratory condition. It details subjective and objective assessment findings that may be reported by the patient or observed by nurses. These include fatigue, cough, sputum production, decreased breath sounds, and chest pain. The plan involves administering oxygen, proper positioning, mouth care, lung auscultation, and monitoring vital signs and blood gas levels to improve ventilation and gas exchange over 8 hours.

Uploaded by

Christian Apelo Serquillos
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Student Nurses Community

NURSING CARE PLAN ASSESSMENT SUBJECTIVE: The patient may report: Fatigue Cough Pleurisy Sputum production A recent upper respiratory infection or sinus disease DIAGNOSIS Impaired gas exchange related to inflammator y response to pathogen and inadequate airway and alveolar clearance. INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

OBJECTIVE: Decreased breath sound Decreased or unequal chest expansion Tachypnea or dyspnea Splinting due to chest pain

Older adults develop pneumonia when their defense mechanisms cant combat the virulence of the invading organisms or decreased immune response. Noninfectious causes of pneumonia include inhalation of toxic gases, chemicals, or smoke or aspiration of water, food, fluid, or vomitus.

After 8 hours of nursing intervention the patient will: Monitor Pao2 and Paco2 levels to assess if theyre within normal range of the patients baseline values. Monitor level of consciousn ess, heart rate, and respiratory rate. Monitor energy level. Monitor alveolar clearance.

Assist the patient to keep his head, neck, and chest in alignment.

Administer oxygen as ordered. Provide mouth care every 8 hours and as needed, and assess nasal and oral mucous membranes for cracking. Clean the cannula or mask by rinsing with clear, warm water every 4 to 8 hours or as needed. Monitor the results of ABG analysis and pulse oximetry, and document any trends. Auscultate the lungs of the patient on

Positioning the patient in the proper alignment helps maximize ventilation potential and improve gas exchange by allowing expansion of the lungs. Oxygen provides symptomatic relief of hypoxemia or hypoxia. Oxygen can dry out the mucous membranes.

After 8 hours of nursing intervention the patient was able to: Maintain Pao2 and Paco2 levels within normal range or within his baseline status. Demonstrat e that breathing is easier. Demonstrat e that fatigue is reduced. Use correct breathing techniques.

To prevent growth of microorganisms. These test results indicate the lungs ability to oxygenate the blood. To determine if the patient has

Student Nurses Community oxygen therapy every 2 hours. atelectasis.

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