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 during each shift while on antibiotics for 90 days.

Plan/Approach:

1. Monitor for Respiratory Distress:

   • Step-by-Step Approach: Monitor for signs and symptoms of respiratory distress every shift and notify MD if any are present.
   • Monitoring Strategies: Use pulse oximetry and respiratory rate monitoring to assess patient condition.

2. Temperature Monitoring:

   • Step-by-Step Approach: Check temperature every shift while the patient is on antibiotics.
   • Technological Aids: Utilize digital thermometers for accurate readings.

3. Fluid Intake:

   • Step-by-Step Approach: Encourage fluid intake if not contraindicated.
   • Educational Efforts: Educate patient and family on the importance of hydration in managing pneumonia.

4. Energy Conservation:

   • Step-by-Step Approach: Encourage the patient to pace activities to conserve energy.
   • Educational Efforts: Provide guidance on energy conservation techniques.

5. Medication Administration:

   • Step-by-Step Approach: Administer antibiotics and nebulizer treatments as ordered.
   • Monitoring Strategies: Regularly assess patient response to medications and document effectiveness.

6. Vital Signs Monitoring:

   • Step-by-Step Approach: Monitor vital signs as needed.
   • Technological Aids: Use automated vital sign monitors.

7. Oxygen Saturation:

   • Step-by-Step Approach: Check oxygen saturation as needed.
   • Technological Aids: Use pulse oximeters to monitor oxygen levels.

8. Oxygen Therapy:

   • Step-by-Step Approach: Administer oxygen via face mask or nasal cannula as ordered by MD/NP.
   • Monitoring Strategies: Regularly check the oxygen delivery system for proper functioning.

9. Lung Sounds Monitoring:

   • Step-by-Step Approach: Check lung sounds as ordered.
   • Educational Efforts: Teach patient and family about the importance of lung sound assessments.

Rationale:

• Monitor for Respiratory Distress: Early detection of respiratory distress prevents complications and ensures timely medical intervention.
• Temperature Monitoring: Fever is a common symptom of pneumonia and requires close monitoring to assess treatment effectiveness.
• Fluid Intake: Adequate hydration helps thin mucus and supports overall recovery.
• Energy Conservation: Conserving energy prevents fatigue and supports recovery.
• Medication Administration: Ensures effective treatment of pneumonia and reduces the risk of complications.
• Vital Signs Monitoring: Vital signs provide crucial information about the patient’s health status.
• Oxygen Saturation: Monitoring ensures that the patient maintains adequate oxygen levels.
• Oxygen Therapy: Supplemental oxygen supports respiratory function.
• Lung Sounds Monitoring: Regular assessments detect changes in lung condition, allowing for prompt intervention.

Actions:

1. Monitor for Respiratory Distress:

   • Staff will monitor for signs and symptoms of respiratory distress every shift and notify MD if any are present.

2. Temperature Monitoring:

   • Staff will check temperature every shift while the patient is on antibiotics.

3. Fluid Intake:

   • Staff will encourage fluid intake if not contraindicated.

4. Energy Conservation:

   • Staff will encourage the patient to pace activities to conserve energy.

5. Medication Administration:

   • Staff will administer antibiotics and nebulizer treatments as ordered.

6. Vital Signs Monitoring:

   • Staff will monitor vital signs as needed.

7. Oxygen Saturation:

   • Staff will check oxygen saturation as needed.

8. Oxygen Therapy:

   • Staff will administer oxygen via face mask or nasal cannula as ordered by MD/NP.

9. Lung Sounds Monitoring:

   • Staff will check lung sounds as ordered.