Updated Care Plan for Respiratory Infection

Category / Primary Body System:

Respiratory System / Infection Control

Problem:

The patient is at risk for complications due to a respiratory infection.

Goal:

The patient will exhibit no signs or symptoms of respiratory distress, and the respiratory infection will resolve within 30 days.

Plan/Approach:

1. Monitoring for Respiratory Distress:

   • Step: Monitor for signs and symptoms of respiratory distress every shift and notify the MD if any are observed.
   • Rationale: Early detection of respiratory distress allows for prompt intervention and prevents complications.
   • Actions: Assess for symptoms such as shortness of breath, wheezing, increased respiratory rate, and cyanosis. Document findings and report any concerns immediately.

2. Temperature Monitoring:

   • Step: Check the patient’s temperature every shift while on antibiotics.
   • Rationale: Monitoring temperature helps detect fever, a common sign of infection, and assesses the effectiveness of antibiotic treatment.
   • Actions: Measure and record the patient's temperature every shift, and notify the healthcare provider if there is a persistent fever or any abnormal readings.

3. Fluid Intake Encouragement:

   • Step: Encourage fluid intake if not contraindicated.
   • Rationale: Adequate hydration helps thin respiratory secretions, making them easier to expel and promoting overall recovery.
   • Actions: Offer fluids frequently, monitor intake, and ensure the patient stays hydrated. Adjust the plan if the patient has any fluid restrictions.

4. Energy Conservation:

   • Step: Encourage the patient to pace activities to conserve energy.
   • Rationale: Conserving energy helps prevent fatigue and supports the body's ability to fight infection.
   • Actions: Assist the patient in planning and spacing out activities, encouraging rest periods between activities.

5. Antibiotic Administration:

   • Step: Administer antibiotics as ordered.
   • Rationale: Proper administration of antibiotics is essential for effectively treating the respiratory infection.
   • Actions: Ensure timely administration of prescribed antibiotics, monitor for side effects, and document the administration.

6. Nebulizer Treatments:

   • Step: Administer nebulizer treatments as ordered.
   • Rationale: Nebulizer treatments help open airways, reduce inflammation, and improve breathing.
   • Actions: Prepare and administer nebulizer treatments according to the physician’s orders, and monitor the patient’s response.

7. Vital Signs Monitoring:

   • Step: Monitor vital signs as needed.
   • Rationale: Regular monitoring of vital signs provides important information about the patient’s overall condition and response to treatment.
   • Actions: Check and record vital signs regularly, including heart rate, respiratory rate, and blood pressure, and report any significant changes to the healthcare provider.

8. Oxygen Saturation Monitoring:

   • Step: Check oxygen saturation as indicated.
   • Rationale: Monitoring oxygen saturation helps assess the patient’s oxygenation status and the effectiveness of oxygen therapy.
   • Actions: Use a pulse oximeter to measure oxygen saturation levels, document the readings, and adjust oxygen therapy as needed.

9. Oxygen Therapy:

   • Step: Administer oxygen via face mask or nasal cannula as ordered by the MD/NP.
   • Rationale: Supplemental oxygen helps maintain adequate oxygen levels in patients with respiratory infections.
   • Actions: Set up and administer oxygen therapy according to the physician’s orders, and monitor the patient’s response.

10. Lung Sound Assessment:

    • Step: Check lung sounds as ordered.
    • Rationale: Regular assessment of lung sounds helps detect changes in the respiratory status and the presence of congestion or other issues.
    • Actions: Auscultate lung sounds every shift, document findings, and report any abnormal sounds such as crackles or wheezes to the healthcare provider.