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  • Nursing Care Plan

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    Mikki lor Puagan
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    This document provides an assessment, objectives, interventions, and evaluation for a patient experiencing an ineffective breathing pattern due to community-acquired pneumonia. The short term goals were to achieve maximum lung expansion and normal oxygen saturation within 30 minutes to 1 hour. The long term goal was a normal breathing pattern within 24-48 hours. Interventions included supplemental oxygen, positioning, and breathing exercises. The goals were met, indicating effective nursing care.

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    This document provides an assessment, objectives, interventions, and evaluation for a patient experiencing an ineffective breathing pattern due to community-acquired pneumonia. The short term goals were to achieve maximum lung expansion and normal oxygen saturation within 30 minutes to 1 hour. The long term goal was a normal breathing pattern within 24-48 hours. Interventions included supplemental oxygen, positioning, and breathing exercises. The goals were met, indicating effective nursing care.

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    Flag for inappropriate content
    Download as docx, pdf, or txt
    96 views1 page

    Nursing Care Plan

    Uploaded by

    Mikki lor Puagan
    This document provides an assessment, objectives, interventions, and evaluation for a patient experiencing an ineffective breathing pattern due to community-acquired pneumonia. The short term goals were to achieve maximum lung expansion and normal oxygen saturation within 30 minutes to 1 hour. The long term goal was a normal breathing pattern within 24-48 hours. Interventions included supplemental oxygen, positioning, and breathing exercises. The goals were met, indicating effective nursing care.

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    © All Rights Reserved
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    of 1

    ASSESSMENT EXPLANATION OF OBJECTIVES INETERVENTION RATIONALE EVALUATION

    THE PROBLEM
    Subjective: It is considered the state in LTO: Dx:  To detect early signs LTO:(GOAL MET)
     “She told me which the rate, depth, Within 24-48 hours of  Assessed and of respiratory distress. After 24-48 hrs. of effective
    that I can’t timing, and rhythm, or the effective nursing record O2  To be able to identify nursing interventions, the
    breathe” stated pattern of breathing is interventions, the patient: saturation and increased in work of patient had:
    by the mother altered. When the breathing - Will be able to have a respiratory rate, breathing by retraction - Will achieved normal
    pattern is ineffective, the normal breathing pattern depth, and quality.  Breathing may respiratory rate with normal
    Objectives: body is most likely not and presence of breath  Monitored for use increase as lung breathing pattern
     BP: 90/60 getting enough oxygen to of accessory compliance
    mmHg the cells. Increased capillary STO: muscles Supplemental oxygen STO:(GOAL MET)
     HR: 115 bpm permeability and Within 30 minutes-1  Observed for nasal helps reduce After 30 minutes-1 hour of
     RR: 33 cpm vasodilation to provide hour of effective nursing flaring hypoxemia and relieve effective nursing interventions,
     Temp: 37.8 °C adequate perfusion, oxygen, interventions, the patient respiratory distress the patient had:
     Weak looking and nutrients to tissue and will be able to: Tx:  To maximize lung - Achieved maximum lung
    cells. Imbalance of - Achieved maximum  Administered expansion expansion with normal O2
     Malaise
    inflammatory response and lung expansion with oxygen as ordered  To conserve energy saturation and able to perform
     Poor appetite
    organ shutting down due to adequate ventilation.  Positioned in semi and avoid overexertion properly the breathing
     Noted - Return O2 saturation to technique
    physiologic progression of fowler and fatigue
    “shortness of normal
    infecting including lungs.  Assisted patient  Measure to allow
    breath” - Demonstrate
    This may cause ineffective with ADL patient to participate
    breathing pattern. appropriate breathing
    Nursing diagnosis: in maintain health
    technique. Edx:
     Ineffective status and improve
    Reference: NANDA
    breathing  Instructed proper ventilation
    pattern related breathing  This prevents fatigue
    to Community techniques and reduces oxygen
    acquired  Encourage to have demand
    Pneumonia rest periods in  For patient to gain
    between daily more understanding
    activities about the treatment
     Educated regarding being given
    the importance of
    compliance to
    given medication.

    Passed by: Mikki Lor B. Puagan

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