Question

The RN is updating the plan of care for a patient with a medical diagnosis of pneumonia. The patient was admitted yesterday, with a respiratory rate of 28, crackles in the right middle and lower lobes, a dry cough, and oxygen saturation of 90% on room air. The patient was using a bedside commode until earlier today, because of shortness of breath with any activity. The following nursing diagnoses and outcomes were included in the plan of care at the time of admission:

Nursing diagnosis: Impaired gas exchange related to ventilation perfusion imbalance as evidenced by oxygen saturation of 90%.

Expected outcome: Patient will demonstrate oxygen saturation greater than 95% within 24 hours.

Nursing diagnosis: Ineffective airway clearance related to retained secretions as evidenced by crackles in the right middle and lower lobes.

Expected outcome: Patient will demonstrate clear breath sounds in bilateral upper and lower lobes within 24 hours.

Nursing diagnosis: Ineffective breathing pattern related to hyperventilation as evidenced by shortness of breath and RR of 28 breaths per minute.

Expected outcome: Patient will demonstrate RR between 12-20 breaths per minute within 24 hours.

Nursing diagnosis: Activity intolerance related to imbalance between oxygen supply and demand as evidenced by shortness of breath when ambulating.

Expected outcome: Patient will demonstrate no shortness of breath with ambulation within 24 hours.

The patient has been receiving treatment for the past 24 hours, and currently has a respiratory rate of 20 breaths per minute, crackles in the right lower lobe, breath sounds clear in all other lobes, oxygen saturation of 94% on 2 liters of oxygen via nasal cannula, and denied shortness of breath when ambulating to the bathroom an hour ago.

Initial Discussion Post:

• How will the RN update the plan of care?
• Include one intervention to address each of the nursing diagnoses that are still applicable.
• Provide the rationale for these interventions.

Answer 1

1. The RN will update the plan of care :-

The patient was having impaired gas exchange due to decrease perfusion , evidenced by oxygen saturation of 90% after 24hrs of treatment the has improvement in the gas exchange as evidenced by oxygen saturation of 94%.

Patient had increased respiratory rates and ineffective breathing pattern due to decreased oxygen supply as evidenced by RR of 28 breaths/min.After 24 hrs of treatment the patient have normal RR of 20 breaths/min.

Patient had breathing difficulty on ambulation at the time of admission ,after the treatment for one day the patient is ambulating and deny shortness of breath.

Nursing diagnosis - Ineffective airway clearance related to thick secretions in the airway causing blockage and breathing difficulty evidenced by crackles in the right lower lobe.

Nursing intervention-

1.Administer oxygen by nasal canna at the rate of 2liters.

2.Provide semi -fowlers position to the patient.

3.Providing steam inhalation to the patient.

4.Providing chest physiotherapy and positional drainage.

5.Avoiding exertion.

6.Administering medications to loosen the recreations.

Rationale 1. Oxygen supply will increase the ventilation perfusion

2. Semi -fowlers position will help in easy removal of recreation and help in lung expansion.

3. Steam inhalation loosens the thick secretions.and help in expectoration.

4. Chest physiotherapy and positional drainage will also help in loosening of thick secretions.

5. Exertion causes increased demand of oxygen so,avoid exertion.

6. Medications with action of loosening recreation or which decreases the production of recreation must be administered.