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Care Plan Sample

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Patient: Room Number: Code Status: FULL

Reason for admission: Pneumonia

Nursing Diagnosis Patient Expected Prioritized Nursing Rationale


Outcome Interventions

Ineffective airway Pt. will be free of 1. Assess respiration Tachypnea, shallow


clearance dyspnea, rate. respirations and
dyspnea symptoms
r/t increased Demonstrate effective
production of cough,
sputum secondary have clear lung 2. Auscultate lung Listen for
to sounds, and sounds. fluid/secretions
present in lungs.
(crackles, wheezes etc)
Pneumonia a.e.b achieve a patent
dyspnea, airway by
crackles heard 10/9/2016. 3. Treat with Decrease sections,
bilaterally in lung medications infection, and edema.
fields, and Prescribed (Antibiotics,
ineffective
nonproductive Mucolytics, bronchodilators
cough. etc)
4. Elevate head of Improve breathing by
bed. allowing chest
expansion.

5. Increase/encourage Facilitate exporation


fluids. of secretions.

6. Teach proper Facilitate effective


cough and deep cough to get rid of
breathing Secretions.

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