Pneumonia
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| Assessment data (subjective and objective findings relevant to THIS diagnosis) | Goals / expected outcomes | Nursing intervention | Rationale | Evaluation |
|---|---|---|---|---|
| Patient exhibits tachypnea, labored breathing, decreased SpO2 levels, reports shortness of breath and chest tightness; auscultation reveals crackles and diminished breath sounds in affected lung areas. | Patient will maintain SpO2 ≥ 92% on room air or prescribed oxygen and demonstrate improved breathing pattern within 48 hours. | Monitor respiratory rate, depth, and effort every 2 hours. | Early detection of respiratory distress allows timely intervention to prevent hypoxia. | Respiratory parameters remain stable or improve, indicating adequate gas exchange. |
| Assess oxygen saturation continuously or at regular intervals using pulse oximetry. | To evaluate oxygenation status and effectiveness of interventions. | SpO2 readings consistently meet target levels or improve over time. | ||
| Encourage deep breathing exercises and use of incentive spirometer every 2 hours while awake. | Promotes alveolar expansion and prevents atelectasis, improving oxygenation. | Patient demonstrates participation and reports decreased dyspnea. | ||
| Position patient in semi-Fowler’s or high Fowler’s position. | Facilitates lung expansion and eases breathing effort. | Patient reports easier breathing and shows improved respiratory effort. | ||
| Administer supplemental oxygen as prescribed and monitor response. | To increase oxygen delivery to tissues and relieve hypoxia. | Oxygen saturation improves and patient reports less shortness of breath. |
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