Care Plan for Pneumonia
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
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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
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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
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Hydration and Energy Conservation
- Encourage fluid intake if not contraindicated
- Encourage the patient to pace activities to conserve energy
Rationale
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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.
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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.
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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
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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.
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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.
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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.