Pneumonia Care Plan 446m3r

HARRIS COLLEGE OF NURSING AND HEALTH SCIENCES WRITTEN NURSING PROCESS NAME William Murphy Nursing Diagnosis

Ineffective Breathing Pattern

MEDICAL DIAGNOSIS: Pneumonia Goal as evidenced by Expected Outcomes*

Patient's breathing pattern will be restored by end of shift

(patient’s problem) R/T: Pneumonia (medical diagnosis/condition)

(broad statement)

as evidenced by unlabored breathing (eupnea), normal breathing rate, and correct use of spirometer by end of shift. AEB:

AEB:

SOB (patient’s S/S)

Productive Cough

DATE 08/03/10

Nursing Interventions**/Rationale

Evaluation of Expected Outcomes***

Assessment Intervention: Assess respiratory rate, rhythm, and depth b/c changes are early warning signs of impending respiratory difficulties.

By shift change the patient completely met her goal. The pt’s breathing was unlabored, with a rate of 14, and was able to effectively use the spirometer.

Therapeutic Intervention: Encourage sustained deep breaths and use of incentive spirometer, promoting deep inspiration that increases oxygenation and prevents atelectasis

By shift change the patient partially met her goal by correctly using her spirometer, however, the patient’s breathing remained labored and tachypnea.

Education Intervention: Teach patient appropriate breathing, coughing, and splinting techniques that facilitate adequate clearance of secretion and prevent atelectasis.

At shift change the patient’s goals were unmet. The patient’s breathing remained labored, tachypnea, and was unable to correctly use her spirometer thus

**

***

(patient’s S/S)

Abnormal Breath Sounds/Wheezing (patient’s S/S)

DATA: Subjective: reported SOB, fatigue, reduced LOC, high anxiety,

Objective: Increased thick yellow sputum; productive cough; wheezing; suction in use; fever; irregular breathing pattern

* Specific Measurable Attainable Realistic Timed

Assessment Interventions Therapeutic Intervention Education Intervention

Completely Met Partially Met Unmet