Nursing Care Plan Assessment Nursing Diagnosis Impaired gas exchange r/t altered oxygen supply as manifested by dyspnea,

abnormal ABG results, Irritability/ restlessness, Abnormal rate, rhythm, depth of breathing and nasal flaring Analysis
Pneumonia develops when foreign matter such as viruses, bacteria, parasites, or fungus enters the lungs and causes inflammation. There are also chemicals that can enter the lungs and cause pneumonia. Additionally, an injury to the lungs may cause pneumonia, but it is much less common. Once this foreign matter enters the body, it provokes a response of the immune system. After that, the person's oxygen levels begin to deplete and he or she begins to breathe faster. The mucus production also begins to increase. As the mucus production increases, the fluid begins to fill the alveoli, which are the small pocket-like sacs in the lungs where gas exchange takes place. As the development of pneumonia progresses, the

Goal and objectives After 2 weeks of nursing intervention, the client will improve ventilation and adequate oxygen tissues by ABGs within clients normal limits and absence of symptoms of respiratory distress. Objectives: To increase the PO2 of the client To normalize the arterial pH of the client To decrease irritability and restlessness of

Interventions

Rationale

Evaluation

The client is irritable and cries continuously. Evident of difficulty of breathing. Increase RR85 bpm Increase HR150 bpm With nasal flaring With ABG results of: pH: 7.50 pO2: 70 pCO2: 28 pHCO3: 24 O2 sat: 87 %

Does the clients ventilation improved and he has adequate oxygen supply after 2 weeks of nursing intervention? __ Yes __ No WHY? Are the interventions safe? __ Yes __ No WHY? Are the interventions appropriate to the client? __ Yes __ No WHY?

- Maintain client airway. Place client in position of comfort with head of bed elevated 30 to 45 degrees. - Reposition the client frequently. Suction as

- These measures enhance lung expansion and reduce respiratory efforts.

- Good pulmonary toilet is

patient's white blood cell count begins to rise. Once the white blood cell count rises, the debris they leave behind also fill the alveoli. All of these things filling the alveoli is what causes pneumonia to become life-threatening very quickly if left untreated.

the client

needed.

To normalize the breathing pattern of the client.

necessary for reducing ventilation/perf usion imbalance and for mobilizing and facilitating removal of secretions to maximize gas exchange. - Prevents exhaustion and reduces oxygen consumption and demands to facilitate resolution of infection.

Are the interventions effective? __ Yes __ No WHY? Are the interventions efficient? __ Yes __ No WHY?

- Encourage the parents to let the patient to have adequate rest and limit activities to w/in client tolerance. Promote calm and restful environment. - Administer supplemental oxygen, as indicated via appropriate route: nasal cannula, mask, or high-flow rebreathing mask.

- Supplemental oxygen is necessary for correction of hypoxemia with failing respiratory effort.

- Keep environment allergen/ pollutant free.

- To reduce irritant effect of dust and chemicals on airway. - To treat the underlying condition. - Having good nutrition will improve stamina and reduce the work of breathing.

- Administer medications, as indicated. Emphasize to the SO about the importance of nutrition of the patient.