Pneumonia is an inflammatory condition of S: the lung. It is The relative often said that the characterized client seems to as including have difficulty inflammation in breathing. of the parenchyma of O: the lung (that Pale in is, the alveoli) appearance and abnormal alveolar filling (+) use of accessory with fluid muscles when (consolidation breathing and exudation). Tachypnea Typical RR: 29 cpm symptoms associated with pneumonia include cough, chest pain, fever, and difficulty in
Objectives and goals
Interventions
Assess respirations: respirations: Long Term quality, rate, pattern, Goal depth and breathing After nursing effort. intervention the patient will demonstrate improved ventilation and oxygenation of tissues by ABGs within Auscultate lung sounds. patient’s Also assess for the acceptable presence of jugular vein range and distention (JVD) or absence of tracheal deviation. symptoms of respiratory distress.
Assess for signs of hypoxemia. Short Term Goals / Monitor vital signs. Outcomes: After 4 hours of nursing
Rationale
evaluation
Rapid, shallow breathing and Patient is free of hypoventilation affect gas signs of distress. exchange by affecting CO 2 ABGs show PaCO 2 levels. Flaring of the between 35-45 nostrils, dyspnea, use of Pts respirations are accessory muscles, tachypnea of a normal rate and /or apnea are all signs of and depth. severe distress that require immediate intervention. Patient’s lungs sounds are clear to Absence of lung sounds, JVD auscultate and / or tracheal deviation throughout all could signify a lobes. Pneumothorax or Hemothorax. Patient is free of signs of hypoxia.
Tachycardia, Tachycardia, restlessness, diaphoresis, headache, lethargy and confusion are all signs of hypoxemia. Initially with hypoxia and hypercapnia blood pressure
Patient is normotensive normotensive with heart rate 60 – 100 bpm and respiratory rate 1020.
breathing.
intervention: Patient will maintain normal arterial blood gas (ABGs). Patient will be awake and alert. Patient will demonstrate a normal depth, rate and pattern of respirations.
Monitor ABGs.
Position patient with head of bed 45 degrees (if tolerated).
(BP), heart rate and respiratory rate all increase. As the condition becomes more severe BP may drop, ABGs show PaCO2 heart rate continues to be between 35-45 and rapid with arrhythmias and PaO2 between 80 – respiratory failure may ensue. 100. Increasing PaCO2 and decreasing PaO 2 are signs of respiratory failure.
Promotes better lung expansion and improved gas exchange. Pace activities and provide rest periods to prevent fatigue. Even simple activities, such as bathing, can increase oxygen consumption and cause fatigue.
Patient’s rate and pattern are of normal depth and rate at 45 degree angle. No changes to cardiopulmonary status noted during activity. Patients SaO2 remains >90% during activities.
