The RN is updating the plan of care for a patient with a medical diagnosis of pn

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.

Explanation / Answer

RN care plan update:

The RN update plan of care was depends on the patient's care complexity and the severity condition. After the computerized representation of clinical data in the health care organizations the update can be done once every 24 hours. But in the intensive care due to the patient complexity it is often done one or more time per shift. The evaluation and assessment can occurs every time when you talk or look at a patient, every interacting session will be recorded. So the physician will record and update the plan which will be communicated to the nurse.

Nursing diagnoses:

Ineffective airway clearance

Ineffective breathing pattern

Acute pain

Imbalanced Nutrition

Nursing intervention in this situation: Monitoring the respiratory rate, depth and effort, nasal flaring and abnormal breathing patterns. Teach proper ways of coughing and breathing to patient.

Ex: Breath holding for 2 seconds, taking a deep breath and cough two or three times in succession.

Nursing Interventions and Rationales:

Obtain appropriate labs (sputum cultures, antibiotic troughs, ABGs, etc.)

Promote airway clearance

Ensure patent airway

Cluster care

Promote nutrition

Encouraging coughing and deep breathing

Administer supplemental oxygen as appropriate

Promote rest

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