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:
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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.
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Temperature Monitoring:
- Step-by-Step Approach: Check temperature every shift while the patient is on antibiotics.
- Technological Aids: Utilize digital thermometers for accurate readings.
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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.
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Energy Conservation:
- Step-by-Step Approach: Encourage the patient to pace activities to conserve energy.
- Educational Efforts: Provide guidance on energy conservation techniques.
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Medication Administration:
- Step-by-Step Approach: Administer antibiotics and nebulizer treatments as ordered.
- Monitoring Strategies: Regularly assess patient response to medications and document effectiveness.
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Vital Signs Monitoring:
- Step-by-Step Approach: Monitor vital signs as needed.
- Technological Aids: Use automated vital sign monitors.
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Oxygen Saturation:
- Step-by-Step Approach: Check oxygen saturation as needed.
- Technological Aids: Use pulse oximeters to monitor oxygen levels.
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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.
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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:
-
Monitor for Respiratory Distress:
- Staff will monitor for signs and symptoms of respiratory distress every shift and notify MD if any are present.
-
Temperature Monitoring:
- Staff will check temperature every shift while the patient is on antibiotics.
-
Fluid Intake:
- Staff will encourage fluid intake if not contraindicated.
-
Energy Conservation:
- Staff will encourage the patient to pace activities to conserve energy.
-
Medication Administration:
- Staff will administer antibiotics and nebulizer treatments as ordered.
-
Vital Signs Monitoring:
- Staff will monitor vital signs as needed.
-
Oxygen Saturation:
- Staff will check oxygen saturation as needed.
-
Oxygen Therapy:
- Staff will administer oxygen via face mask or nasal cannula as ordered by MD/NP.
-
Lung Sounds Monitoring:
- Staff will check lung sounds as ordered.
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