How to Complete Right Lobe Pneumonia Nursing Care Plan

INSTRUCTIONS

STUDENT NAME:			DATE:				COURSE:
CLIENT INITIALS:		DATE OF ADMISSION:				AGE:		GENDER:
HT:	WT:			ALLERGIES:
CODE STATUS:
RACE/ETHNICITY:					CULTURAL CONSIDERATIONS:
RELIGION/SPIRITUAL CONSIDERATIONS:
OCCUPATION/HOBBIES/RECREATIONAL ACTIVITIES:
LIVING SITUATION/WITH WHOM: (home, assisted living, LTC, etc)
SOCIAL HISTORY: (tobacco, ETOH, illicit drugs, family dynamics)
I. ADMITTING MEDICAL DIAGNOSIS:
Definition: (from Taber’s)
Etiology/pathophysiology: (NOT from Wikipedia etc.)
Common signs/symptoms:
Potential complications:
Medical treatments: with rationales and references
Lab tests, x-rays, etc.: with rationales and references
IV. CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS: (what led up to this admission)

Medication generic name	Reason for taking	Action of med	Blackbox warnings and adverse reactions	Intended therapeutic effects

Note: must be complete and every item must have an entry.

Wash hands – standard precautions
Introduction – introduce self and purpose of assessment to relieve anxiety and role function. Identify client by two methods (NAME AND BIRTHDATE). Use Mr. Mrs. or Miss until indicates use of first names. Response to introduction: misunderstood or understood
General: hygiene, () good, () poor ________; affect: _________; mood: ________ () glasses; () hearing aid R or L; () ambulation device _________; oral mucosa: moist; pink; facial expression: __________; body posture: ______________
Orientation: () person, () place and () time; speech: ____________________
Vital signs** –
Temp: _____ – oral, rectal, tympanic
Pulse: ______ – Rate, strength, regularity ____________________
Respirations: ____ – character? ______
Pulse ox: _____________ %
BP ___________ – lying, sitting, standing, site: _________
Ht: __________ Wt: _____________
IV tubes: Type of IV device? ________; location _________; erythema, edema, pain; IV fluid is ___________ at ___________per hour; currently left in bag_________ mL
Pupil check: PERLA; Sluggish, brisk, normal; accommodation; cornea clear
Neck veins: HOB at 45 degrees; distended () yes () no
Upper extremities: compare bilateral pulses: () radial; () brachial; compare: rate, regularity and strength of pulses () equal; () right stronger; () left stronger; capillary refill ___ sec; hand grasp with two fingers () equal; () unequal; paresthesia’s: _________________________ () edema _____________ () pitting: __________
Skin: turgor: check over sternum, return at _____ sec; Color: () pink; () jaundiced; () pale; () cyanotic; () moist; use back of hand to check skin temperature: () warm () hot () cool; bilateral musculature: () equal, well defined; () flabby; () firm
Heart tones: listen at aortic, pulmonic, tricuspid and mitral, then count Apical pulse with your stethoscope; listen one full minute; Rate _____; rhythm () regular () irreg; Clarity of sounds: ______; extra sounds ________
Breath sounds: Assess anterior and posterior from side to side comparing both. Have patient breathe deeply, do not move stethoscope too rapidly to avoid hyperventilation. Note use of accessory muscles: () clear throughout; () crackles or rales at __________; () wheezes or rhonchi at _____________; () other sounds ______________; () diminished; Cough: ________; sputum: ___________; O2 @ ____ LPM; () NC; () mask.
Bowel sounds: assess all 4 quads, do not touch Abd. Before auscultation, as it may disrupt normal sounds. Umbilicus is midpoint of quadrants. RLQ () active ()absent ()hyperactive ()hypoactive RUQ ()active ()absent () hyperactive ()hypoactive LUQ ()active ()absent ()hyperactive ()hypoactive LLQ ()active ()absent ()hyperactive ()hypoactive light palpation: ()soft ()hard ()distended ()symmetrical () other ; Last BM __________: soft, or hard formed; liquid
Genitourinary: voiding stream: ______; color: ____; clear or cloudy; nocturia; incontinence; Perineum: rash, drainage, etc.?
Back: () edema; () pressure sores: () scapula () sacrum () hip R or L; () heels R or L, () ankles R or L, () thoracic spine, () ears R or L, () occiput Describe: ______________________________________________________________________________________________________________________________________
Lower extremities: Compare bilateral pulses () pedal () posterior tibial () popliteal () femoral () equal () right stronger () left stronger () edema: up to ________________ () pitting; capillary refill _____ seconds; () feet push against resistance equal bilaterally; () paresthesias __________________
Pain: location _________________________ duration ______________________________ radiate _________________________________ makes it better __________________makes it worse ________________ description : () sharp () dull () stabbing ()other _____________ on a scale of 1-10, 10 is worst ___________
Closure: Let patient know you are finished and when you will return. Offer bedpan or bathroom. () rails up; () bed in low position () call light in reach; () Telephone in reach; () dispose of all linens clean all equipment; wash hands; document findings.
**: assessment must be completed before administering any medications and treatments.

Cluster any clues from history and health assessment here:

Physiologic symptoms:

Psychologic/spiritual symptoms:

Knowledge deficit issues:

Other:

NARRATIVE DOCUMENTATION OF CARE

Nursing diagnosis statement: Three parts

*NANDA approved diagnosis

*R/T

Related To

Etiology/cause or pathophysiology – what is happening – describe diagnosis in “layman’s terms”

*AEB

Signs and symptoms/defining characteristics – those items from assessment that indicate this diagnosis.

What is Maslow hierarchy level?

Outcomes/Goals:

1 LTG and 2 STG.

Must contain these:

S- specific

M-measurable

A-achievable

R-realistic

T-time bound

Must be stated according to what patient should accomplish.

“Patient will…”

Interventions: Must have 3 – both Independent and Dependent.

State in terms of what you will do to help patient achieve their goals.

“Nurse will…”

Must be individualized to patient. Title sections:

Assess

Teach

Perform

Then use bullet points for each section.

Rationales: Evidence that lets you know your interventions should work.

Must be scientifically evidence based.

Must include reference with page numbers.

Documentation: when you performed the interventions, how did they work?

State clearly how your patient responded to your interventions.

List each goal and determine evaluation:

Part 1 – State Met, Unmet or Partially met

Should you continue the interventions, or do they need modified (depends on how effective they were- see documentation).

Part 2 – Care Plan Status: Continue, Discontinue or Modify.

Do you need to modify goal and/or intervention

Maslow’s

LTG

STG 1

STG 2

Assess

Teach

Perform

References: Here or last page

LTG

STG 1

STG 2

Nursing diagnosis statement: Three parts

*NANDA approved diagnosis

*R/T

Related To

Etiology/cause or pathophysiology – what is happening – describe diagnosis in “layman’s terms”

*AEB

Signs and symptoms/defining characteristics – those items from assessment that indicate this diagnosis.

What is Maslow hierarchy level?

Outcomes/Goals:

1 LTG and 2 STG.

Must contain these:

S- specific

M-measurable

A-achievable

R-realistic

T-time bound

Must be stated according to what patient should accomplish.

“Patient will…”

Interventions: Must have 3 – both Independent and Dependent.

State in terms of what you will do to help patient achieve their goals.

“Nurse will…”

Must be individualized to patient. Title sections:

Assess

Teach

Perform

Then use bullet points for each section.

Rationales: Evidence that lets you know your interventions should work.

Must be scientifically evidence based.

Must include reference with page numbers.

Documentation: when you performed the interventions, how did they work?

State clearly how your patient responded to your interventions.

List each goal and determine evaluation:

Part 1 – State Met, Unmet or Partially met

Should you continue the interventions, or do they need modified (depends on how effective they were- see documentation).

Part 2 – Care Plan Status: Continue, Discontinue or Modify.

Do you need to modify goal and/or intervention

Maslow’s

LTG

STG 1

STG 2

Assess

Teach

Perform

References: Here or last page

LTG

STG 1

STG 2

Nursing diagnosis statement: Three parts

*NANDA approved diagnosis

*R/T

Related To

Etiology/cause or pathophysiology – what is happening – describe diagnosis in “layman’s terms”

*AEB

Signs and symptoms/defining characteristics – those items from assessment that indicate this diagnosis.

What is Maslow hierarchy level?

Outcomes/Goals:

1 LTG and 2 STG.

Must contain these:

S- specific

M-measurable

A-achievable

R-realistic

T-time bound

Must be stated according to what patient should accomplish.

“Patient will…”

Interventions: Must have 3 – both Independent and Dependent.

State in terms of what you will do to help patient achieve their goals.

“Nurse will…”

Must be individualized to patient. Title sections:

Assess

Teach

Perform

Then use bullet points for each section.

Rationales: Evidence that lets you know your interventions should work.

Must be scientifically evidence based.

Must include reference with page numbers.

Documentation: when you performed the interventions, how did they work?

State clearly how your patient responded to your interventions.

List each goal and determine evaluation:

Part 1 – State Met, Unmet or Partially met

Should you continue the interventions, or do they need modified (depends on how effective they were- see documentation).

Part 2 – Care Plan Status: Continue, Discontinue or Modify.

Do you need to modify goal and/or intervention

Maslow’s

LTG

STG 1

STG 2

Assess

Teach

Perform

References: Here or last page

LTG

STG 1

STG 2

SOLUTION: NURSING CARE PLAN FOR Right Lobe Pneumonia

STUDENT NAME:

DATE:

COURSE:

CLIENT INITIALS:MH

DATE OF ADMISSION: 10/25/2022

AGE:72

GENDER:HISPANIC FEMALE

HT: 168 cm

WT: 78 kg

ALLERGIES: No known allergy

CODE STATUS: Full

RACE/ETHNICITY:HISPANIC

CULTURAL CONSIDERATIONS: N/A

RELIGION/SPIRITUAL CONSIDERATIONS: Catholic

OCCUPATION/HOBBIES/RECREATIONAL ACTIVITIES: No known history

LIVING SITUATION/WITH WHOM: Lives at home with husband

SOCIAL HISTORY: No history of tobacco or illicit drugs use. Has a strong family support system.

I. ADMITTING MEDICAL DIAGNOSIS: Right Lobe Pneumonia

Right Lobe pneumonia, also known as lober pneumonia is an inflammation of the lungs caused by infections by viruses, bacteria, or fungi.

Etiology/pathophysiology

Pneumonia is a type of acute lower respiratory infection of the lungs. The etiology of pneumonia I poorly understood due to the fact that the microbes causing the disease are numerous and varied. However, fungi, viruses, and bacteria are common causative agents for pneumonia (Jain et al., 2022). Once infected, the disease causes exudative fluid to accumulate in the pulmonary parenchyma causing its inflammation and respiratory dysfunction. Furthermore, the microorganisms break several local defense mechanisms causing intra-alveolar exudates (Jain et al., 2022). The common mechanisms affected by the disease include the systemic defense mechanism which gets impaired thus allowing for infection by intracellular organisms, the mucociliary system among cigarette smokers, and the cough reflex. The infection may be spread through inhalation, aspiration, hematogenous spread, and direct extension from adjacent infected areas (Cilloniz, Caedozo, & Garcia-Vidal, 2018).

Common signs/symptoms:

The common signs and symptoms for pneumonia include coughing, increased rate of breathing (breath of 24 bpm and above shows a patient is critically ill), pyrexia, crackling sound, decreased breath sounds, tachycardia, temperature above 37. 8^oC, respiratory rate greater than 20 bpm, and pulse rate greater than 100bpm (Htun ey al., 2019)

Potential complications: some of the potential complications of pneumonia include respiratory failure, empyema, pericarditis, pleural effusion, endobronchial obstruction, and lung abscesses.

Medical treatments

Different methods are used to treat pneumonia. The method chosen is dependent on the type and severity of pneumonia, a patient’s age and the overall health. Treatment is aimed as curing the infection and preventing complications. Patients whose pneumonia is as a result of bacterial infection are often treated using antibiotics, fungal infections using antifungal drugs, while those caused by viruses are treated using antiviral medications (Grief & Loza, 2018). Individuals with severe pneumonia may be treated at the hospital using IV lines and oxygen therapy to increase the amount of oxygen in the blood. Others may require to be put on a ventilator. One may also require a surgical operation to remove some of the severely infected or damaged parts of the lungs. Patients should take their medications as prescribed to prevent complications such as sepsis, respiratory failure, acute respiratory distress syndrome, and lung abscesses. In most case, pneumonia causes fever which can be controlled at home by using aspirin or acetaminophen. Patients are also advised to drink plenty of warm fluids to loosen secretions and to open their airways. Furthermore, one should avoid exposure to smoke and dust.

Lab tests, x-rays, etc.: with rationales and references

Chest x-ray to diagnose pneumonia and differentiate it from other respiratory tract infection, its location, and extent of infection. This test revealed infiltrates in right lower lobe, indicating pneumonia.
Sputum and blood culture tests-used to pinpoint the cause of the infection. Results revealed that the infection was as a result of streptococcus penumoniae (File 2011).
Urinary antigen test to detect presence of soluble pneumococcal antigen or Legionella antigen in urine. Pneumococcal urinary antigen detected (File 2011).
Computed tomography (CT) scan to obtain a more detailed image of the lungs.

5. PCR tests, a molecular diagnostic technique to identify the type of detect the exact cause of the infection and to guide in the type of therapy to use (Torres et al., 2016).

IV. CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS: (what led up to this admission)

The patient was admitted to the medical unit with complains of right lobe pneumonia. The patient reports sharp chest pain with coughing and shortness of breath during activity. In a scale of 1-10, the patient reports her pain at 6/10. Prior to admission, she was experiencing symptoms of productive dry cough, fever, malaise, and rust-colored sputum, and was diagnosed with influenza 10 days before today’s admission. Her symptoms got worse yesterday as her temperature had increased significantly to 38.4 ⁰C. She also experienced shaking, chills, and productive cough of rust-colored sputum. After being assessed by her primary care provider, it was agreed that the patient be admitted for monitoring and treatment. She was given acetaminophen 650mg at 1400hrs and her vital signs taken at 1200 hours. Her temperature was 38.1⁰c, pulse=104bpm, PH= 7.3, HCO₃=22, PCO₂=58, PO₂=72, respirations=24/min, and blood pressure=112/72mmHg. Her intake was 375 ml and output 300 ml. The patient’s oxygen concentration was 94% on nasal cannula with oxygen at 3L/min. The patient’s respiration were labored when she moved out of her bed, but later improved when she returned to bed. The doctors recommended for her oxygen concentration to be raised to above 94% and be encouraged to cough and deep breath using incentive spirometer. It was also recommended that the healthcare providers start patient education regarding the patient’s condition and its management.

Medication generic name	Reason for taking	Action of med	Blackbox warnings and adverse reactions	Intended therapeutic effects
Hydrochlorothiazide 25 mg orally once daily	To treat hypertension	This is a thiazide-type diuretic which acts on the distal convoluted tube thereby inhibiting the sodium chloride co-transporter system.	The medication causes dizziness and therefore one should not drive or operate machines once they have taken the drug. Alcohol, pain relievers and sleeping pills may make one fell dizzy or faint. Some of the side effects of the medication include nausea, vomiting, weakness, drowsiness, confusion, pain and cramps, increased heartbeat, and electrolyte imbalance.	The intended effects include treatment of edema and excessive fluid retention, caused by medications and medical problems of the kidney, heart and liver.
Moxifloxacin 400 mg piggyback infusion once daily	To treat infections caused by bacteria such as pneumonia	This is a bacterial dependent anti-infective agent that works binding to DNA gyrase and topoisomerase thereby interfering with bacterial survival.	The drug increases chances of developing tendinitis or tendon rupture. Some of adverse effects of the drug include skin rash, hives, peeling of the skin, fever, and swelling in most of the body parts,	Intended therapeutic effect is to treat and prevent plague
Heparin 5000 units subcutaneously twice daily	Used to prevent blood clotting	The drug works by binding to antithrombin and inducing conformational changes thereby making the antithrombins an efficient inactivator of coagulation factor.	The drug may cause bruising and cause the body to take a longer time to stop bleeding. Therefore, it is important to notify a healthcare provider in case of excessive nosebleeds, unusual bleeding from gums, and brown or tarry stool.	The medication is critical in preventing excessive coagulation.
Acetaminophen 650 mg orally every 6 hours PRN pain	Used to treat pain and fever.	This is a non-opioid analgesic and antipyretic that works by inhibiting prostaglandin synthesis that preventing pain.	Excessive intake of the drug may cause liver damage. This damage may call for liver transplantation or can even cause death. Some of the side effects of the drug include peeling of the skin, skin rash, and hoarseness, breathing difficulties, and swelling of the face, tongue, eyes, hands, and feet.	To relieve mild to moderate pain.
Guaifenesin elixir 100 mg orally every 4 hours PRN Cough	To treat cough that may be caused by asthma, chronic bronchitis, and emphysema.	Belong to a class of medications known as expectorants which works by loosening mucus and thus easing the process of coughing.	The medication may cause an allergic reaction, which should be reported to a healthcare provider. Adverse effects of the drug include diarrhea, headache, hives, nausea, skin rash, and vomiting.	The medication clears mucus during a lung congestion.

Note: must be complete and every item must have an entry.

Wash hands – standard precautions
Introduction – introduce self and purpose of assessment to relieve anxiety and role function. Identify client by two methods (NAME AND BIRTHDATE). Use Mr. Mrs. or Miss until indicates use of first names.
Response to introduction: Understood
General: hygiene, (✓) good, () poor, affect: Restricted ; mood: _irritable (x) glasses; (x) hearing aid R or L; (x) ambulation device, oral mucosa: moist, facial expression: feverous face, body posture: good
Orientation: (✓) person, (✓) place and (✓) time; speech: slurred
Vital signs**
Temp: _4⁰C____ oral, rectal, tympanic
Pulse: 104bpm Rate, strength, regularity ___Irregular pulse rate_________________
Respirations: 24bpm ____ – character: labored
Pulse ox: ____94%_________
BP __112/72mmH measured while lying, sitting, and standing, site: __Heart _______
Ht: _168 cm_________ Wt: ______78 kg_______
IV tubes: Type of IV device? _N/A_______; location ____N/A_____; erythema, edema, pain; IV fluid is ___N/A________ at ___________per hour; currently left in bag_________ mL
Pupil check: PERLA; normal, equal, round, and reactive to light and accommodation. The cornea is clear.
Neck veins: HOB at 45 degrees; distended (✓) yes () no

Upper extremities: compare bilateral pulses: () radial; (✓) brachial; compare: rate, regularity and strength of pulses (✓) equal; () right stronger; () left stronger; capillary refill _ >2 __ sec; hand grasp with two fingers (✓) equal; () unequal; paresthesia’s: Tingling and itching_________________________ (✓) edema _____________ (✓) pitting: ____3+______
Skin: turgor: check over sternum, return at _ > 2 ____ sec; Color: () pink; () jaundiced; (✓) pale; () cyanotic; () moist; use back of hand to check skin temperature: () warm (✓) hot () cool; bilateral musculature: () equal, well defined; (✓) flabby; () firm
Heart tones: listen at aortic, pulmonic, tricuspid and mitral, then count Apical pulse with your stethoscope; listen one full minute; Rate __52BPM___; rhythm () regular (✓) irregular; Clarity of sounds: _S1 and S2 sounds heard _____; extra sounds __Heart murmurs heard_____
Breath sounds: Assess anterior and posterior from side to side comparing both. Have patient breathe deeply, do not move stethoscope too rapidly to avoid hyperventilation. Note use of accessory muscles: () clear throughout; (✓) crackles and rales at ___right lobe_______; (X) wheezes or ___________; (X) other sounds ______________; () diminished; Cough: __✓______; sputum: _✓__________; O2 @ _3___ LPM; () NC; (X) mask.

Bowel sounds: assess all 4 quads, do not touch Abd. Before auscultation, as it may disrupt normal sounds. Umbilicus is midpoint of quadrants. RLQ () active (✓)absent ()hyperactive ()hypoactive RUQ (✓)active ()absent () hyperactive ()hypoactive LUQ ()active (✓)absent ()hyperactive ()hypoactive LLQ ()active (✓)absent ()hyperactive ()hypoactive light palpation: ()soft ()hard (✓)distended ()symmetrical () other ; Last BM _6 hours ago_________: soft and liquid

Genitourinary: voiding stream: _Frequent_____; color: dark and cloudy, Perineum: rash, drainage, etc.?
Back: (✓) edema; () pressure sores: () scapula () sacrum () hip R or L; (✓) heels R or L, () ankles R or L, () thoracic spine, () ears R or L, () occiput Describe: _6/10___ chest pain
Lower extremities: Compare bilateral pulses () pedal () posterior tibial () popliteal (✓) femoral () equal () right stronger () left stronger () edema: up to ____3+_____ (✓) pitting; capillary refill __>2 ___ seconds; () feet push against resistance equal bilaterally; (✓) paresthesias __________________
Pain: location _Chest_______________ duration 3 days ago____________________________ radiate ________From chest to all parts________________ makes it better Rest________________ makes it worse ____Activity____________ description : (✓) sharp () dull () stabbing ()other _____N/A________ on a scale of 1-10, 10 is worst ______6/10_____
Closure: Let patient know you are finished and when you will return. Offer bedpan or bathroom. () rails up; () bed in low position () call light in reach; () Telephone in reach; () dispose of all linens clean all equipment; wash hands; document findings.
**: assessment must be completed before administering any medications and treatments.

Cluster any clues from history and health assessment here:

Physiologic symptoms: Inflammation, edema, cough, fever, difficulties breathing, irregular heartbeat, low oxygen concentration, shortness of breath, chills, fatigue, and sharp chest pain.

Psychologic/spiritual symptoms:

Confusion, poor orientation, lakc of inspiration, and inability to let things go away.

Knowledge deficit issues: Patient’s inability to participate in activities that maximize oxygenation and airway clearance.

Other: N/A

NARRATIVE DOCUMENTATION OF CARE

S: A review of the medical record reveals that the patient is a 72 year old Hispanic woman who has been admitted to the facility with a diagnosis of right lobe pneumonia. The patient lives at her home with her husband. The patient reports sharp chest pain with coughing and shortness of breath during activity. She reports her pain at 6/10. Prior to admission, she was experiencing symptoms of productive dry cough, fever, malaise, and rust-colored sputum, and was diagnosed with influenza 10 days before today’s admission. Her symptoms got worse yesterday as her temperature had increased significantly to 38.4 ⁰C. She also experienced shaking, chills, and productive cough of rust-colored sputum. After being assessed by her primary care provider, it was agreed that the patient be admitted for monitoring and treatment.

O: After assessment, her vital signs were a temperature of 38.1⁰c, pulse=104bpm, PH= 7.3, HCO₃=22, PCO₂=58, PO₂=72, respirations=24/min, and blood pressure=112/72mmHg. Her intake was 375 ml and output 300 ml. The patient’s oxygen concentration was 94% on nasal cannula with oxygen at 3L/min. The patient’s respiration were labored when she moved out of her bed, but later improved when she returned to bed. Her neck vein was distended; bilateral pulses were radial, capillary refill less than 2 seconds, pitting edema 3+, S1 and S2 sounds heard, pale and hot skin, irregular heartbeat, crackling sound when breathing. Bowel sounds were active, frequent voiding, and dark cloudy stool. The patient has a productive dry cough, fever, and produces rust-colored sputum. The patient’s hygiene is good and she is oriented x3. Her pupils are equal and normal. She has a sluggish speech. The neck veins are distended while her bilateral pulses are radial and equal. She has good range of motion regarding her elbows, fingers, and shoulder. Grip strength are equal bilaterally.

A: Right lobe pneumonia.

P: The patient will be evaluated and educated on her diagnosis and how to manage it at home. She may also require supplemental oxygen at home to help improve her oxygen saturation.

Nursing diagnosis statement: Three parts

*NANDA approved diagnosis

*R/T

Related To

Etiology/cause or pathophysiology – what is happening – describe diagnosis in “layman’s terms”

*AEB

Signs and symptoms/defining characteristics – those items from assessment that indicate this diagnosis.

What is Maslow hierarchy level?

Outcomes/Goals:

1 LTG and 2 STG.

Must contain these:

S- specific

M-measurable

A-achievable

R-realistic

T-time bound

Must be stated according to what patient should accomplish.

“Patient will…”

Interventions: Must have 3 – both Independent and Dependent.

State in terms of what you will do to help patient achieve their goals.

“Nurse will…”

Must be individualized to patient. Title sections:

Assess

Teach

Perform

Then use bullet points for each section.

Rationales: Evidence that lets you know your interventions should work.

Must be scientifically evidence based.

Must include reference

Documentation: when you performed the interventions, how did they work?

State clearly how your patient responded to your interventions.

List each goal and determine evaluation:

Part 1 – State Met, Unmet or Partially met

Should you continue the interventions, or do they need modified (depends on how effective they were- see documentation).

Part 2 – Care Plan Status: Continue, Discontinue or Modify.

Do you need to modify goal and/or intervention

Right lobe pneumonia related to alteration of oxygen saturation, inflammation of the tracheal, bronchial, and edema, chest pain, and accumulation of mucus in the airways.

Signs and symptoms exhibited by the patient include fever, lowered oxygen saturation, productive cough and rusty-coloured sputum, rapid shallow breathing, shaking chills, chest pain, audible breathing sounds, and shortness of breath.

The patient will demonstrate improved gaseous exchange, ventilation and oxygenation.
The patient will use the prescribed drugs to treat the infection and avoid complications.
The patient will participate in activities that maximize oxygenation and achieve airway clearance.

The nurse will assess the patient’s heart rhythm, rate, depth of respiration, and chest movement and support her to maintain airway clearance and support to improve gaseous exchange (Vera, 2023).
The nurse will teach the patient about her condition and medications and help administer medications and pharmacological support (Vera, 2023).
The nurse will perform diagnostic tests and offer support to promote rest, effective breathing patterns, and fluid balance.

Airway clearance is important in addressing secretions and ineffective coughing. This can be achieved by supporting the patient undertake voluntary coughing. Furthermore, it is imperative to support the client undertake lung expansion activities to improve airway clearance (Vera, 2023).
Teaching the patient about her condition will assist her understand factors that make her condition worse so as to avoid them. Medications are critical in reducing discomfort due to coughing, facilitating respiration, clearing airways, and preventing complications (Vera, 2023).
Promoting rest is critical in reducing metabolic demands and fatigue, improving breathing, and supports the clearing of secretions form the lungs (Vera, 2023).

The intervention helped reduce accumulated secretions in the lungs thus improving the patient’s breathing pattern. The lung expansion activities also reduced the patient’s coughing. Chest pains were also reduced from a scale of 2/10 to 6/10.
The patient understood her condition and committed to minimize exposure to smoke, dust, and activity as they made her condition worse. The use of medications including analgesics, bronchodilators, and expectorants helped cleat the patient’s airways, supported respiration, and improved her cough. Indeed, the medications resolved much of the patient’s issues and improved her vital signs.
Adequate rest helped minimize exhaustion, balance oxygen supply and demand, and improved the patient’s breathing pattern.

The first goal of assisting the patient to demonstrate improved gaseous exchange, ventilation and oxygenation was attained and thus should be continued.
The second goal on using the prescribed medication to treat the infection and avoid complications was met and therefore the goal and the intervention should be continued.
Lastly, the goal on participating in activities that maximize oxygenation and achieve airway clearance was met. This implies the need to continue on the goal and the intervention without any modification.

References

Cilloniz, C., Cardozo, C. & Garcia-Vidal, C. (2018). Epidemiology, pathophysiology, and microbiology of community-acquired pneumonia. Annals of Research Hospitals, 12, 1,1-13.

Htun, T., Sun, Y., Chua, H. & Pang, J. (2019). Clinical features for diagnosis of pneumonia among adults in primary care setting: A systematic and meta- review. Scientific Reports, 9, (20), 1-12. doi: 10.1038/s41598-019-44145-y

File, T. (2011). New diagnostic tests for pneumonia: What is their role in clinical practice? Clinical Chest Methods, 32(3), 417-430.

Grief, S. & Loza, J. (2018). Guidelines for the evaluation and treatment of pneumonia. Primary Care,45(3), 485-503.

Jain, V., Vashisht, R., Yilmaz, G.& Bharswaj, A.(2022). Pneumonia Pathology. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526116/

Torres, A., Lee, N., Cillioniz, C., Vila, J. & Eerden, M. (2016). Laboratory diagnosis of pneumonia in the molecular age. European Respiratory Journal, 48, 1764-1778. DOI: 10.1183/13993003.01144-2016

Vera, M. (2023). Pneumonia nursing care plans. https://nurseslabs.com/pneumonia-nursing-care-plans/#h-7-promoting-rest-and-improving-tolerance-to-activity

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Right Lobe Pneumonia Nursing Care Plan

How to Complete Right Lobe Pneumonia Nursing Care Plan

INSTRUCTIONS

SOLUTION: NURSING CARE PLAN FOR Right Lobe Pneumonia

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Right Lobe Pneumonia Nursing Care Plan

Right Lobe Pneumonia Nursing Care Plan

How to Complete Right Lobe Pneumonia Nursing Care Plan

INSTRUCTIONS

SOLUTION: NURSING CARE PLAN FOR Right Lobe Pneumonia

References

Get this and other Nursing Care Plan Assignment Help from our Experts Today

Nursing Care Plan For Diabetic microvascular multiple cranial neuropathy Sample

Nursing Care Plan for Gastroesophageal reflux disease

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