Care Plan for Pneumonia

Category / Primary Body System

• Respiratory System

Problem

• Patient is at risk for complications due to pneumonia.

Goal

• Patient will not exhibit signs or symptoms of respiratory distress every shift while on antibiotics.

Plan/Approach

1. Monitoring and Assessment

   • Monitor for signs and symptoms of respiratory distress every shift and notify MD/NP if any (e.g., shortness of breath, increased respiratory rate, use of accessory muscles)
   • Check temperature every shift while on antibiotics
   • Monitor vital signs as needed
   • Check oxygen saturation as needed
   • Check lung sounds as ordered

2. Medication and Treatment

   • Administer antibiotics as ordered
   • Administer nebulizer treatments as ordered
   • Provide oxygen via face mask or nasal cannula as ordered by MD/NP

3. Hydration and Energy Conservation

   • Encourage fluid intake if not contraindicated
   • Encourage the patient to pace activities to conserve energy

Rationale

1. Monitoring and Assessment

   • Regular monitoring of respiratory status helps in early detection of complications, enabling timely interventions.
   • Frequent temperature checks can detect fever, a common symptom of infection, which requires immediate attention.
   • Monitoring vital signs and oxygen saturation provides critical information about the patient’s respiratory and overall health status.
   • Regular lung sound assessments help identify changes in respiratory function, such as crackles or wheezes, indicating fluid accumulation or airway constriction.

2. Medication and Treatment

   • Administering antibiotics as prescribed ensures effective treatment of the bacterial infection causing pneumonia.
   • Nebulizer treatments help deliver medication directly to the lungs, improving breathing and clearing secretions.
   • Providing supplemental oxygen ensures adequate oxygenation, especially if the patient is experiencing respiratory distress.

3. Hydration and Energy Conservation

   • Adequate fluid intake helps thin respiratory secretions, making them easier to expel.
   • Pacing activities helps the patient conserve energy, reducing the risk of fatigue and exacerbating respiratory distress.

Actions

1. Monitoring and Assessment

   • Monitor for signs of respiratory distress every shift, noting any shortness of breath, increased respiratory rate, or use of accessory muscles. Notify MD/NP immediately if any signs are observed.
   • Check and document temperature every shift while the patient is on antibiotics.
   • Monitor and document vital signs (blood pressure, heart rate, respiratory rate, temperature) regularly and as needed.
   • Check oxygen saturation levels using a pulse oximeter as needed, documenting and reporting any levels below the prescribed threshold.
   • Auscultate lung sounds as ordered, documenting any findings such as crackles, wheezes, or diminished breath sounds.

2. Medication and Treatment

   • Administer antibiotics according to the prescribed schedule, monitoring for effectiveness and side effects.
   • Provide nebulizer treatments as ordered, ensuring proper technique and patient comfort.
   • Administer supplemental oxygen via face mask or nasal cannula as ordered, adjusting the flow rate to maintain target oxygen saturation levels.

3. Hydration and Energy Conservation

   • Encourage the patient to drink fluids regularly, unless contraindicated by other medical conditions.
   • Advise the patient to pace activities and provide assistance with activities of daily living (ADLs) to conserve energy.