Medical Diagnosis: Community Acquired Pneumonia (adult)

Problem: Impaired Gas Exchange

Assessment Nursing Scientific Planning Interventions Rationale Evaluation

Diagnosis Explanation

Subjective: Short Term: Short Term:

(none) Impaired gas Pneumonia is an After 4 hours of 1. Establish 1. To gain pt’s trust The pt shall
exchange inflammation of NI, the pt will Rapport have
related to the lung participate in participated in
alveolar – parenchyma treatment 2. To obtain treatment
capillary caused by regimen within 2. Monitor Vital baseline data regimen within
membrane various level of ability Signs level of ability
Objective:
changes microorganisms, 3. To evaluate
• Restlessness secondary to including Long Term: Long Term:
degree of
• Irritability community bacteria, After 4 days of The pt shall
3. Note RR, use of compromise
• Diaphoresis acquired mycobacteria, NI, the pt will have
accessory
• Productive pneumonia chlamydiae, demonstrate demonstrated
muscles &
Cough mycoplasma, improved improved
pursed lip
• Adventitious fungi, parasites ventilation and 4. To determine ventilation and
breathing
breath and viruses. As absence of presence of absence of
sounds the lung symptoms of productive cough symptoms of
• Confusion parenchyma respiratory 4. Auscultate respiratory
• Abnormal and alveoli of distress breath sounds distress
ABGs, the lungs are 5. To assess for
hypoxia, inflamed it respiratory
hypercapnia impairs gas insufficiency
• Cyanosis exchange due 5. Evaluate pulse
• Abnormal RR to the oximetry to
• Nasal flaring alterations in determine
• Tachycardia oxygenation 6. For comparative
the alveoli
• use of purposes
which is the site
accessory for actual gas
muscles 6. Review
exchange. 7. To maintain
pertinent

This NCP was made with love by NursesLabs.com

(ignore the Monkey)
• Delayed laboratory data patent airway
Capillary
refill
7. Elevate HOB 8. For optimal lung
expansion

8. Reposition 9. For drainage of

client secretions

9. Instruct deep 10.To liquefy

breathing and secretions
coughing
exercises

11.To promote
10.Instruct to comfort
increase OFI

12.To reduce oxygen

11.Fix bed linens needs and
consumption

12.Encourage
adequate bed 13.To reduce irritant
rest effects on airway

14.To improve
13.Keep ventilation,
environment airway and gas
free from exchange
allergens

This NCP was made with love by NursesLabs.com

(ignore the Monkey)
14.Administer
Bronchodilators
, O2 therapy,
nebulizations

This NCP was made with love by NursesLabs.com

(ignore the Monkey)