Lafuente, Maryca Shaina M.

BSN 2-2

Pediatric Ward

CI: Professor Verame

Nursing Care Plan

Patients Name: Baby D
Initial Diagnosis: Severe Pneumonia
Nursing Diagnosis: Impaired gas exchange r/t collection of secretions affecting oxygen exchange across alveolar membrane.
Short-term Goal: at the end of my shift, the patients condition will lighten and minimal formation of secretion will only occur.
Long-term Goal: after hospital confinement patient will be free of secretion enabling condition of oxygen exchange normally.
ASSESSMENT
>O:
- Dyspnea
-Shortness of
breath
-Wheezes upon
auscultation
-Nasal Flaring
-Altered Chest
Excursion
-Use of
accessory
muscles in
breathing
V/S taken as
follows:
T: 36.7 C
P: 138
R: 67

DIAGNOSIS

INFERENCE

PLANNING

>Impaired gas
Exchange
related to
alveolarcapillary
membrane
changes
(inflammatory
effects)

>Pneumonia is an
excess of fluid in the
lungs resulting from an
inflammatory process.
The inflammation is
triggered by many
infectious organisms
and by inhalation of
irritating agents.

Short term:
After 6 hours
of nursing
interventions the
patient will
demonstrate ease in
breathing.

Bronchospasm, which
occurs in many
pulmonary diseases,
reduces the caliber of
the small bronchi and
may cause dyspnea,
static secretions and
infections.
Bronchospasm can
sometimes be detected
by stethoscope when
wheezing or
diminished breath
sounds are heard.
Increase mucous
production along with
decrease mucous
ciliarys action,
contributes to further

Long term:
After 2-3 days
of nursing
interventions the
patients
S.O will verbalize
understanding
of the causative
factors that
could aggravate
the condition
and appropriate
factors that
could help the
patient relive
from gas
exchange
impairment

INTERVENTION

RATIONALE

>Administer Oxygen as ordered

> Improves gasexchange decrease

work of breathing.

> Position the patient in semi

fowlers position

>To facilitate lung

expansion to
enhance breathing.

>Administer antimicrobials as
prescribed.

>Suction as indicated.

>Assist with nebulizer treatments.

>Assess respiratory rate, depth and

>These drugs are

used to combat most
of the microbial
pneumonias.
>Stimulates cough or
mechanically clears
airway in patient
who is unable to
cough effectively.
>Facilitates
liquefaction and
removal of
secretions.

>Signs of
improvement in

EVALUATION
Short term:
The patient shall have
demonstrated ease in
breathing.

Long term:
The patients S.O
will
verbalize understanding
of the causative
factors that could
aggravate the
condition and
appropriate factors that
could help the patient
relive from gas exchange
impairment.

reduction in the caliber

of the bronchi and
results in decrease air
flow and decrease gas
exchange.

ease.

condition should
occur within 24- 48
hrs.
>This signs may indicate
hypoxia.

>Assess LOC, distress and irritability.

>Observe skin color and capillary refill.

>Monitor body temperature.

>Monitor effectiveness of
antimicrobial therapy.

>Determine
circulatory adequacy,
which is necessary for
gas exchange to
tissues.
>High fever greatly
increases metabolic
demands and oxygen
consumption and
alters cellular
oxygenation.
>Promotes
expectoration,
clearing or infection.
To facilitate lung
expansion to
enhance breathing.