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    NCP and FDAR

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    Kyrajane Esguerra
    The 15-year-old male patient presented with symptoms of community-acquired pneumonia including diminished breath sounds and crackles, increased work of breathing, and an oxygen saturation of 92% on room air. Objective findings on exam and chest X-ray confirmed the presence of pneumonia. The plan was to initiate antibiotic therapy, administer oxygen therapy, encourage coughing and deep breathing exercises, and closely monitor the patient's respiratory status and vital signs with admission for further management and observation.

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    NCP and FDAR

    Uploaded by

    Kyrajane Esguerra
    47 views3 pages
    The 15-year-old male patient presented with symptoms of community-acquired pneumonia including diminished breath sounds and crackles, increased work of breathing, and an oxygen saturation of 92% on room air. Objective findings on exam and chest X-ray confirmed the presence of pneumonia. The plan was to initiate antibiotic therapy, administer oxygen therapy, encourage coughing and deep breathing exercises, and closely monitor the patient's respiratory status and vital signs with admission for further management and observation.

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    NCP-and-FDAR

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    The 15-year-old male patient presented with symptoms of community-acquired pneumonia including diminished breath sounds and crackles, increased work of breathing, and an oxygen saturation of 92% on room air. Objective findings on exam and chest X-ray confirmed the presence of pneumonia. The plan was to initiate antibiotic therapy, administer oxygen therapy, encourage coughing and deep breathing exercises, and closely monitor the patient's respiratory status and vital signs with admission for further management and observation.

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

    NCP and FDAR

    Uploaded by

    Kyrajane Esguerra
    The 15-year-old male patient presented with symptoms of community-acquired pneumonia including diminished breath sounds and crackles, increased work of breathing, and an oxygen saturation of 92% on room air. Objective findings on exam and chest X-ray confirmed the presence of pneumonia. The plan was to initiate antibiotic therapy, administer oxygen therapy, encourage coughing and deep breathing exercises, and closely monitor the patient's respiratory status and vital signs with admission for further management and observation.

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    SCENARIO:

    A 15-year-old male patient arrives at the emergency room presenting with symptoms suggestive of community-acquired pneumonia. He
    subjectively complains of a persistent cough that is "keeping me up at night' and describes his chest pain as "sharp and worsening with deep
    breaths. Objective data reveals diminished breath sounds and crackles upon auscultation of the left lower lung fields, along with increased work
    of breathing characterized by accessory muscle use and nasal flaring. The patient appears pale and sweaty, demonstrating signs of easy
    fatigability, and exhibits limited physical movement due to discomfort and respiratory distress. Vital signs indicate a temperature of 38.2°C,
    heart rate of 110 bpm, respiratory rate of 24 breaths/min, and oxygen saturation of 92% on room air. Chest X-ray confirms the presence of
    patchy infiltrates consistent with pneumonia. The plan includes initiating antibiotic therapy, pain management, and close monitoring of
    respiratory status, with admission for further management and observation.

    Nursing Care Plan (NCP) for Community-Acquired Pneumonia


    Patient: 15-year-old male presenting with symptoms suggestive of Community-Acquired Pneumonia
    ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
    Objective Data: - Impaired Gas The plan includes - Administer oxygen -Oxygen therapy - Improved oxygenation
    - Diminished Exchange related to initiating antibiotic therapy to maintain improves oxygenation status as evidenced by
    breath sounds in alveolar-capillary therapy, pain oxygen saturation and prevents normal respiratory rate
    left lower lung membrane changes management, and above 92% hypoxemia(deficient and oxygen saturation
    fields secondary to close monitoring of oxygenated blood) above 92%
    - Presence of pneumonia. respiratory status,
    crackles in left - Ineffective with admission for - Reduced pain intensity
    lower lung fields Breathing Pattern further management -Assess pain intensity -Analgesics relieve pain and improved ability to
    - Increased work related to respiratory and observation. and administer and promote patient take deep breaths
    of breathing, distress and analgesics as comfort
    accessory muscle increased work of prescribed
    use, nasal flaring breathing - Restoration of effective
    - Pale and sweaty - Risk for Decreased -Encourage and assist -Breathing exercises breathing pattern with
    appearance Cardiac Output with coughing and facilitate airway decreased work of
    - Limited physical related to fever and deep breathing clearance and improve breathing
    movement due to tachycardia exercises ventilation
    discomfort and - Maintenance of
    respiratory distress -Monitor vital signs and -Vital signs monitoring adequate cardiac output
    - Vital Signs: respiratory status detects changes in the with resolution of fever
    Temperature: closely patient's condition and stabilization of heart
    38.2°C rate
    - Heart Rate: 110 -Administer respiratory -Respiratory
    bpm medications as medications help in
    - Respiratory Rate: prescribed bronchodilation and
    24 breaths/min - secretion clearance
    Oxygen Saturation:
    92% on room air
    - Chest X-ray
    confirms patchy
    infiltrates
    consistent with
    pneumonia

    Subjective Data:
    - "keeping me up at
    night' and
    describes his chest
    pain as "sharp and
    worsening with
    deep breaths

    Focus, Data, Action, and Response (FDAR) Chart

    Focus Data Action Response


    Impaired gas exchange due to Subjective Data - Administer oxygen therapy - Respiratory rate stabilizes
    pneumonia - he complains of a persistent to maintain oxygen saturation within normal range.
    cough that is "keeping me up above 92%. - Oxygen saturation improves
    at night' and describes his - Monitor respiratory status to >92% on supplemental
    chest pain as "sharp and closely, including rate, depth, oxygen.
    worsening with deep breaths and effort. - Patient reports decreased
    - Position patient in semi- respiratory distress and
    Objective Data Fowler's position to improve improved comfort.
    -diminished breath sounds, lung expansion.
    crackles, increased work of - Encourage coughing and
    breathing, and nasal flaring. deep breathing exercises for
    - Vital signs: Temperature secretion clearance.
    38.2°C, heart rate 110 bpm,
    respiratory rate 24
    breaths/min, oxygen
    saturation 92% on room air.
    - Chest X-ray confirms patchy
    infiltrates consistent with
    pneumonia

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