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Nursing ANALYSIS Objectives and Interventions Rationale evaluation

(Pneumonia)
Diagnosis goals
Impaired Gas Pneumonia is
Exchange r/t an
altered oxygen Assess respirations:
supply inflammatory Long Term Rapid, shallow breathing and Patient is free of
quality, rate, pattern,
condition of Goal depth and breathing hypoventilation affect gas signs of distress.
S: the lung. It is After nursing exchange by affecting CO2 ABGs show PaCO2
effort.
 The relative often intervention the levels. Flaring of the between 35-45
said that the characterized patient will nostrils, dyspnea, use of Pts respirations are
client seems to as including demonstrate accessory muscles, tachypnea of a normal rate
have difficulty inflammation improved and /or apnea are all signs of and depth.
in breathing. of the ventilation and severe distress that require
parenchyma of oxygenation of immediate intervention.
O: the lung (that tissues by Patient’s lungs
 Pale in is, the alveoli) ABGs within sounds are clear to
Auscultate lung sounds.
appearance and abnormal patient’s Absence of lung sounds, JVD auscultate
Also assess for the
 (+) use of alveolar filling acceptable presence of jugular vein and / or tracheal deviation throughout all
accessory with fluid range and distention (JVD) or could signify a lobes.
muscles when (consolidation absence of tracheal deviation. Pneumothorax or
breathing and symptoms of Hemothorax. Patient is free of
 Tachypnea exudation). respiratory signs of hypoxia.
 RR: 29 cpm Typical distress.
symptoms Assess for signs of
associated hypoxemia. Tachycardia, restlessness,
with diaphoresis, headache, Patient is
pneumonia Short Term lethargy and confusion are all normotensive with
include cough, Goals / Monitor vital signs. signs of hypoxemia. heart rate 60 – 100
chest pain, Outcomes: bpm and
fever, and After 4 hours of Initially with hypoxia and respiratory rate 10-
difficulty in nursing hypercapnia blood pressure 20.
breathing. intervention: (BP), heart rate and
respiratory rate all increase.
Patient will As the condition becomes
maintain more severe BP may drop, ABGs show PaCO2
normal arterial heart rate continues to be between 35-45 and
blood gas Monitor ABGs. rapid with arrhythmias and PaO2 between 80 –
(ABGs). respiratory failure may ensue. 100.

Patient will be Increasing PaCO2 and Patient’s rate and


awake and decreasing PaO2 are signs of pattern are of
alert. Position patient with respiratory failure. normal depth and
head of bed 45 degrees rate at 45 degree
Patient will (if tolerated). angle.
demonstrate a Promotes better lung
normal depth, expansion and improved gas No changes to
rate and pattern exchange. cardiopulmonary
of respirations. status noted during
Pace activities and activity.
provide rest periods to Patients SaO2
prevent fatigue. remains >90%
Even simple activities, such during activities.
as bathing, can increase
oxygen consumption and
cause fatigue.