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    Nursing Care Plan For Pneumonia NCP

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    deric
    The patient presented with symptoms of pneumonia including difficulty breathing, rapid breathing, cough with yellow sputum, diminished breath sounds, and fever. The nursing care plan diagnoses ineffective airway clearance related to increased respiratory secretions from bacterial or viral invasion causing inflammation and secretions in the lungs. The short term goal is to mobilize secretions and maintain a clear airway within 8 hours through deep breathing exercises, coughing exercises, increased fluids, monitoring of vital signs, positioning, and auscultating the lungs. Dependent interventions include administering ordered medications, mucolytics, bronchodilators, expectorants, and nebulizations as needed.

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    Nursing Care Plan For Pneumonia NCP

    Uploaded by

    deric
    197K views3 pages
    The patient presented with symptoms of pneumonia including difficulty breathing, rapid breathing, cough with yellow sputum, diminished breath sounds, and fever. The nursing care plan diagnoses ineffective airway clearance related to increased respiratory secretions from bacterial or viral invasion causing inflammation and secretions in the lungs. The short term goal is to mobilize secretions and maintain a clear airway within 8 hours through deep breathing exercises, coughing exercises, increased fluids, monitoring of vital signs, positioning, and auscultating the lungs. Dependent interventions include administering ordered medications, mucolytics, bronchodilators, expectorants, and nebulizations as needed.

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    Nursing Care Plan for Pneumonia NCP

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    The patient presented with symptoms of pneumonia including difficulty breathing, rapid breathing, cough with yellow sputum, diminished breath sounds, and fever. The nursing care plan diagnoses ineffective airway clearance related to increased respiratory secretions from bacterial or viral invasion causing inflammation and secretions in the lungs. The short term goal is to mobilize secretions and maintain a clear airway within 8 hours through deep breathing exercises, coughing exercises, increased fluids, monitoring of vital signs, positioning, and auscultating the lungs. Dependent interventions include administering ordered medications, mucolytics, bronchodilators, expectorants, and nebulizations as needed.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    197K views3 pages

    Nursing Care Plan For Pneumonia NCP

    Uploaded by

    deric
    The patient presented with symptoms of pneumonia including difficulty breathing, rapid breathing, cough with yellow sputum, diminished breath sounds, and fever. The nursing care plan diagnoses ineffective airway clearance related to increased respiratory secretions from bacterial or viral invasion causing inflammation and secretions in the lungs. The short term goal is to mobilize secretions and maintain a clear airway within 8 hours through deep breathing exercises, coughing exercises, increased fluids, monitoring of vital signs, positioning, and auscultating the lungs. Dependent interventions include administering ordered medications, mucolytics, bronchodilators, expectorants, and nebulizations as needed.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    The key takeaways are that the patient has pneumonia with symptoms of rapid breathing, cough with yellow sputum, and diminished breath sounds. The nursing care plan involves assessing the patient, making a diagnosis, planning interventions to clear secretions and improve breathing, and evaluating the effectiveness of the interventions.

    Based on the assessment findings of rapid breathing, cough with yellow sputum production, diminished breath sounds, and vital sign abnormalities, the patient's diagnosis is pneumonia likely caused by a bacterial or viral infection.

    Nursing interventions to help improve the patient's condition include encouraging deep breathing and coughing exercises, increasing fluid intake, positioning the patient in high back rest position, auscultating lung sounds, and monitoring respiratory status.

    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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