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NCP 28-1
NCP 28-1

NURSING CARE PLAN

Patient with Pneumonia

NURSING DIAGNOSIS
PATIENT GOALS

Impaired gas exchange related to uid and exudate accumulation at the capillary-alveolar membrane as evidenced by
decreased breath sounds, abnormal arterial blood gases, restlessness, confusion, and somnolence.
1. Maintains adequate alveolar oxygen-carbon dioxide exchange
2. Clears lungs of uids and exudates

OUTCOMES (NOC)
Respiratory Status: Gas Exchange

INTERVENTIONS (NIC) AND RATIONALES

Respiratory Monitoring

Auscultate breath sounds, noting areas of decreased/absent ventilation, and presence of adventitious
sounds to obtain ongoing data on patients response to therapy.
Monitor rate, rhythm, depth, and effort of respirations to determine respiratory status.
Monitor for increased restlessness, anxiety, and air hunger to detect increasing hypoxemia.
Monitor patients ability to cough effectively to promote secretion removal.

PaO2 _____
PaCO2 _____
Oxygen saturation _____
Chest x-ray ndings _____

Measurement Scale
1 = Severe deviation from normal range
2 = Substantial deviation from normal range
3 = Moderate deviation from normal range
4 = Mild deviation from normal range
5 = No deviation from normal range

Dyspnea at rest _____

Dyspnea with mild exertion _____
Restlessness _____
Cyanosis _____

Oxygen Therapy
Administer supplemental oxygen as ordered to promote adequate oxygenation.
Set up oxygen equipment and administer through a heated, humidied system to prevent drying of the
respiratory tract.
Monitor the effectiveness of oxygen therapy (e.g., pulse oximetry, ABGs).
Monitor patients anxiety related to need for oxygen therapy to provide explanations and reassurance.
Periodically check oxygen delivery device to ensure that the prescribed concentration is being delivered.

Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None

NURSING DIAGNOSIS

Ineffective breathing pattern related to inammation and pain as evidenced by dyspnea, tachypnea, nasal aring, altered
chest excursion
Demonstrates effective respiratory rate, rhythm, and depth of respirations

PATIENT GOAL
OUTCOMES (NOC)
Respiratory Status: Ventilation

Respiratory rate _____

Respiratory rhythm _____
Tidal volume _____
Depth of inspiration _____

Measurement Scale
1 = Severe deviation from normal range
2 = Substantial deviation from normal range
3 = Moderate deviation from normal range
4 = Mild deviation from normal range
5 = No deviation from normal range

INTERVENTIONS (NIC) AND RATIONALES

Ventilation Assistance
Monitor respiratory and oxygenation status to determine change in status.
Position to minimize respiratory efforts (e.g., elevate the head of the bed and provide overbed table
for patient to lean on) to reduce oxygen needs.
Encourage slow deep breathing, turning, and coughing to promote effective breathing pattern.
Monitor for respiratory muscle fatigue to provide additional support if needed.
Assist with incentive spirometer as appropriate to promote alveolar ventilation.
Administer medications (e.g., bronchodilators and inhalers) that promote airway patency and gas
exchange.

Dyspnea at rest _____

Restlessness _____
Somnolence _____
Impaired cognition _____

Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None

Continued

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

NCP 28-1
NCP 28-1

NURSING CARE PLANcontd

Patient with Pneumonia

NURSING DIAGNOSIS

Acute pain related to inammation and ineffective pain management and/or comfort measures as evidenced by patient report
of pleuritic chest pain and presence of pleural friction rub, shallow respirations
Reports control of pain following relief measures

PATIENT GOAL
OUTCOMES (NOC)
Pain Control

INTERVENTIONS (NIC) AND RATIONALES

Pain Management

Reports pain controlled _____

Described causal factors _____
Uses nonanalgesic relief measures _____
Uses analgesics appropriately _____

Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated

Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency,

quality, intensity or severity of pain, and precipitating factors to determine appropriate interventions.
Encourage patient to monitor own pain and to intervene appropriately to allow independence and prepare
for discharge.
Teach use of nonpharmacologic techniques (e.g., relaxation, guided imagery, music therapy, distraction,
and massage) before, after, and, if possible, during painful activities; before pain occurs or increases; and
along with other pain relief measures to relieve pain and reduce the need for analgesia.
Use pain control measures before pain becomes severe because mild to moderate pain is controlled
more quickly.
Medicate before an activity to increase participation, but evaluate the hazard of sedation to help minimize
pain that will be experienced.

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.