Katrina Bianca M.

Palanca

RLE 6.2
NURSING CARE PLAN

Assessment

restlessness
irritability
nasal flaring
diaphoresis
tachycardia; PR =
122
has difficulty in
breathing

Nursing
Diagnosis
Impaired gas
exchange
related to
alveolarcapillary
membrane
changes
secondary to
inflammation

Analysis

Goal and
Objective
s

Intervention

Rationale

Evaluation

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

After 6
hours
of nursing
intervention
s the
patient will
demonstrat
e ease in
breathing.

1. Assess respiratory
rate, depth, and
ease.

1. Manifestations of
respiratory distress are
dependent on/and
indicative of the degree
of lung involvement and
underlying general health
status.
2. Cyanosis of nailbeds
may represent
vasoconstriction or the
bodys response to
fever/chills; however,
cyanosis of earlobes,
mucous membranes, and
skin around the mouth is
indicative of systemic
hypoxemia.
3. Restlessness, irritation,
confusion, and
somnolence may reflect
hypoxemia or decreased
cerebral oxygenation.
4. Tachycardia is usually
present as a result of
fever and dehydration

After 6 hours
of nursing
interventions
the patient
have
demonstrated
ease in
breathing.

2. Observe color of
skin, mucous
membranes, and
nailbeds, noting
presence of
peripheral cyanosis
(nailbeds) or central
cyanosis.
3. Assess mental
status.

4. Monitor heart rate

and rhythm.

mucous
production
along with
decrease
mucous
ciliarys action,
contributes to
further
reduction in
the caliber of
the bronchi
and results in
decrease air
flow and
decrease gas
exchange.

5. Monitor body
temperature, as
indicated. Assist with
comfort measures to
reduce fever and
chills, e.g.,
addition/removal of
bedcovers,
comfortable room
temperature, and
tepid or cool water
sponge bath.
6. Maintain bedrest.
Encourage use of
relaxation techniques
and diversional
activities.
7. Assess level of
anxiety. Encourage
verbalization of
concerns/feelings.
Answer questions
honestly. Visit
frequently, arrange
for significant other
and visitors to stay
with patient as
indicated.
8. Observe for
deterioration in
condition, noting
hypotension, copious
amounts of
pink/bloody sputum,

but may represent a

response to hypoxemia.
5. High fever greatly
increases metabolic
demands and oxygen
consumption and alters
cellular oxygenation.

6. Prevents
overexhaustion and
reduces oxygen
consumption and
demands to facilitate
resolution of infection.
7. Anxiety is a
manifestation of
psychological concerns
and physiological
responses to hypoxia.
Providing reassurance
and enhancing sense of
security can reduce the
psychological
component, thereby
decreasing oxygen
demand and adverse
physiological responses.
8. Shock and pulmonary
edema are the most
common causes of death
in pneumonia and require

pallor, cyanosis, and

change in level of
consciousness,
severe dyspnea, and
restlessness.

immediate medical
intervention.