Monday, May 18, 2009


“I have difficulty of breathing”, as verbalized by the patient.
“I have headache upon awakening”, as verbalized by the patient.
Temp. 37.2 degrees Celsius
PR: 146 BPM
RR: 19 breaths/min
BP: 140/90 mmHg
Confusion; restlessness; pale skin; abnormal breathing; nasal flaring; abnormal ABGs/arterial pH as evidenced by hypoxia
Nursing diagnosis
Impaired gas exchange related to inflammatory process, collection of secretions affecting oxygen exchange across alveolar membrane, and hypoventilation possibly evidence by restlessness/change in mentation, dyspnea , tachycardia, pallor and abnormal ABGs/arterial pH evidence of hypoxia
Client will:
Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within client’s normal limits and absence of respiratory distress
Participate in treatment regimen(e.g. breathing exercises, effective coughing, use of oxygen)within level of ability/situation

*Maintain oxygen administration device as ordered to maintain oxygen saturation at 90% or greater

* For patients who should be ambulatory, provide extension tubing or portable oxygen apparatus.

* Position with proper body alignment for optimal respiratory excursion (if tolerated, head of bed at 45 degrees).

* Routinely check the patient’s position so that he or she does not slide down in bed

* Position patient to facilitate ventilation/perfusion matching. Use upright, high-Fowler’s position whenever possible.

* Pace activities and schedule rest periods to prevent fatigue

* Change patient’s position every 2 hours.

* Encourage deep breathing, using incentive spirometer as indicated

* Encourage or assist with ambulation as indicated

*assist with splinting the chest

*Observe signs of respiratory distress(increased rate/restlessness and pallor)

*Teach the patient appropriate deep breathing and coughing

* This provides for adequate oxygenation.

* These promote activity and facilitate more effective ventilation

*This promotes lung expansion and improves air exchange

* This would cause the abdomen to compress the diaphragm, which would cause respiratory embarrassment.
* High-Fowler’s position allows for optimal diaphragm excursion. When patient is positioned on side, the good side should be down

* Even simple activities such as bathing during bed rest can cause fatigue and increase oxygen consumption.
* This facilitates secretion movement and drainage.

* This reduces alveolar collapse.

* This promotes lung expansion, facilitates secretion clearance, and stimulates deep breathing.
*Splinting optimizes deep breathing and coughing efforts.
*These clinical manifestation would be early indicators of hypoxia

*Facilitates adequate air exchange and secretion clearance

Outcome met. The patient demonstrated improved oxygen ventilation and adequate oxygenation. Added to that he participated in treatment regimen for breathing exercise, effective coughing, and use of oxygen



“I feel weak”, as verbalized by the patient.
“ I am having discomfort and difficulty of breathing”, as verbalized by the patient

Temp.: 37.2 degrees Celsius
PR: 140 BPM
RR: 22 breathes/min
BP:140/90 mmHg
Development/severing pallor; excessive coughing

Nursing diagnosis

Activity intolerance related to imbalance between oxygen supply and demand, general weakness possibly evidenced by reports of fatigue,dyspnea,and abnormal ital sign response to activity
Client will:
Report/demonstrate a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue, and vital signs either normal patient’s acceptable range.
*Evaluate patient’s response to activity. Note reports of dyspnea, increase weaknesses/fatigue, and changes in vital signs during and after activities.

*Provide a quiet environment and limit visitors during acute phase as indicated. Encourage use of stress management and diversional activities as appropriate.

*Explain importance of rest in treatment plan and necessity for balancing activities with rest. *Establishes patient’s capabilities/needs and facilitates choice of interventions

*Reduce stress and excess stimulation, promoting rest.

*Bed rest is maintained during acute phase to decrease metabolic demands, thus conserving energy for healing. Activity intolerance restrictions thereafter are determined by individual patient response to activity and resolution of respiration insufficiency Outcome met. The patient reported and demonstrated a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue, and vital signs were normal.

Outcome met. The patient reported and demonstrated a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue, and vital signs were normal.

Nursing care plan for Pneumonia

“I have rapid, labored respirations", as verbalized by the patient.
“I feel restless and weak", as verbalized by the patient.
Temp. 39.2 degrees Celsius
Pulse rate: 70 BPM
Respiration: 24 breaths/min.
BP: 118/70 mm Hg
inspiratory crackles with diminished/adventitious breath sounds right base; excessive sputum production; skin pale; cheeks flushed; chills; use of accessory muscles
Nursing Diagnosis
Ineffective airway clearance related to inability to maintain clear airway as characterized by (+) sputum (+) crackles, rapid, labored respiration, pallor and use of accessory muscles when breathing.


Client will:
Maintain airway patency
expectorate/clear secretions readily
Demonstrate absence/reduction of congestion with breath sounds clear, respirations noiseless, improve oxygen exchange *Encourage deep breathing and coughing exercises


* Encourage use of incentive spirometry, a appropriate

*Increase fluid intake to at least 2000ml/day within cardiac tolerance

*Administer analgesics

*Monitor respirations and breathe sounds, noting rate, rhythm and effort.

*Note chest movement, watching for symmetry, use of accessory muscles, and supraclavicular and intercostals muscle refractions

*Evaluate cough/gag reflex and swallowing ability

*Auscultate breath sounds and assess air movement to ascertain status and note progress
*Observe signs of respiratory distress(increased rate, restlessness/anxiety, use of accessory muscles for breathing)
*Obtain sputum specimen, preferably before antimicrobial therapy is initiated
*Institute respiratory therapy treatments as needed

*monitor/document serial chest X-rays and changes in tidal volume and ABG values


*Deep breathing promotes oxygenation before controlled coughing

*Breathing exercises help maximize ventilation

*Assist to a sitting position with head slightly flexed, shoulders relaxed, and knees flexed

*It improves cough when pain is inhibiting effort

*Provides a basis for evaluating adequacy of ventilation and indicates of respiratory distress and/or accumulation of secretions.

*Presence of nasal flaring and use of accessory muscles of respiration may occur in response to ineffective ventilation

* Determines ability to protect own airway

* Assists in evaluating prescribed treatments and client outcomes

*These clinical manifestation would be early indicators of hypoxia

*Verifies appropriateness of therapy

*A variety of respiratory therapy treatments may be used to open constricted airways and liquefy secretions

*Evaluates the status of oxygenation, ventilation and acid-base balance

Outcome met. The patient maintains airway patency. Expectorated/cleared secretions readily. Demonstrated reduction of congestion with breath sounds clear, respirations noiseless, and improved oxygen exchange