Care Plan for Respiratory Infection

Category / Primary Body System

• Respiratory System

Problem

• Patient is at risk for complications due to respiratory infection.

Goal

• Patient will show no signs or symptoms of respiratory distress and the respiratory infection will resolve within 30 days.

Plan/Approach

1. Monitoring and Assessment

   • Monitor for signs and symptoms of respiratory distress every shift and notify MD/NP if any
   • Check temperature every shift while on antibiotics
   • Monitor vital signs as needed
   • Check oxygen saturation as indicated
   • Check lung sounds as ordered

2. Medication Administration

   • 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 Nutrition

   • Encourage fluid intake if not contraindicated
   • Dietary consult as needed

4. Activity Management

   • Encourage patient to pace activities to conserve energy

5. Patient and Family Education

   • Educate the patient and family about infection prevention and management as needed
   • Provide guidance on signs and symptoms that require immediate medical attention

Rationale

1. Monitoring and Assessment

   • Regular monitoring of respiratory status and vital signs allows for early detection and prompt intervention of any complications, ensuring better outcomes.

2. Medication Administration

   • Administering prescribed antibiotics and nebulizer treatments ensures effective treatment of the respiratory infection and symptom management.
   • Supplemental oxygen helps maintain adequate oxygenation, preventing hypoxia.

3. Hydration and Nutrition

   • Adequate fluid intake supports overall health and helps thin mucus, making it easier to expel.
   • Proper nutrition boosts the immune system and aids in recovery.

4. Activity Management

   • Conserving energy helps the patient recover more effectively by reducing physical stress on the body.

5. Patient and Family Education

   • Educating the patient and family empowers them to participate in care, improving adherence to the treatment plan and preventing complications.

Actions

1. Monitoring and Assessment

   • Assess the patient for signs of respiratory distress (e.g., shortness of breath, use of accessory muscles, cyanosis) every shift.
   • Measure and document the patient's temperature every shift while on antibiotics.
   • Regularly monitor and record vital signs, including heart rate, respiratory rate, and blood pressure.
   • Check oxygen saturation levels using a pulse oximeter as indicated.
   • Auscultate lung sounds to detect any abnormalities such as wheezing, crackles, or decreased breath sounds.

2. Medication Administration

   • Administer antibiotics at the prescribed dosages and intervals.
   • Provide nebulizer treatments as ordered, ensuring the patient uses the nebulizer correctly.
   • Administer supplemental oxygen via face mask or nasal cannula as prescribed, monitoring the patient’s response and adjusting as necessary.

3. Hydration and Nutrition

   • Encourage the patient to drink fluids regularly, unless contraindicated by other medical conditions.
   • Arrange for a dietary consult to ensure the patient’s nutritional needs are met, adjusting the diet plan as necessary.

4. Activity Management

   • Advise the patient to rest and avoid strenuous activities.
   • Schedule periods of activity and rest to prevent fatigue and promote recovery.

5. Patient and Family Education

   • Provide education on respiratory infection management, including the importance of completing the full course of antibiotics and using nebulizers properly.
   • Teach the patient and family to recognize signs and symptoms that require immediate medical attention, such as worsening shortness of breath or high fever.
   • Offer educational materials and answer any questions the patient or family may have.