Articles, Blog

PNEUMONIA CARE PLAN (2018)

October 19, 2019


Hey there friend! My name is Christina Rafano from nursingschoolofsuccess.com
and in this video we are going to walk through a pneumonia nursing care plan, so this will
be an example nursing care plan for you. Now, make sure you check out the Nursing Care
Plan Template video I’ve got for you, that will walk you through how to set up your nursing
care plan and go through everything you’ll need to include. And of course, if you want more care plan
examples, you’ll definitely want to check out the care plan database that I’ve got for
you inside the NursingSOS Membership Community. I’ll put a link in the description below for
you to check that out. Now, let’s go through a pneumonia care plan. Okay, so nursing care plans have 5 main sections,
and it basically follows the nursing process: assessment, diagnosis, planning, implementation
and evaluation. And I’ve actually got a free nursing care
plan template for you to follow along with for this video. There’s a link down below for you to download
that. And I also threw in some other sample care
plans as well, so definitely check that out! So, the first column, you’ll write your nursing
assessment of your patient with pneumonia. So at clinical, make sure you assess your
patient super well and make sure to take really good notes, and then you’ll fill out this
nursing care plan to turn into your instructor. But it all starts with this assessment column. So write out the appropriate nursing assessment
pieces here. So, if we have a patient with pneumonia, we
could say they have a heart rate of 100 beats per minute, a respiratory rate of 20 breaths
per minute, an oxygen saturation of 88%, a cough with mucous coming up (so a productive
cough), arterial blood gas analysis shows respiratory acidosis with a PaCO2 of 47mmHg,
and the patient reports feeling fatigued and out of breath. So you’ll write all of this in the first column
of your pneumonia care plan. And if you want to get fancy, you can break
it up into subjective and objective data, too. Now, you’ll move onto the next column, which
is diagnosis. And here is where you’ll bust out your care
plan book and choose the best NANDA® nursing diagnosis for your patient. I HIGHLY recommend you snag the Nursing Diagnosis
Handbook by Ackley and Ladwig. This is the nursing care plan book I always
recommend to students, it’s a game changer, it basically writes your care plans for you. So if you want to check that out, I’ll put
an affiliate link down below in the description, and if you do decide to purchase that book
through my link, I will receive a small commission, just a little disclaimer there, so thanks
for that, I really appreciate your support, thank you so much. So you’ll go through the list of NANDA® nursing
diagnoses and you’ll pick out the best one that is a priority for your patient. So, as an example for pneumonia, we’ll create
a made up nursing diagnosis of “Not enough oxygen,” friend, this is NOT a real nursing
diagnosis, do not use it in your nursing care plan, I am just making it up as an example. These NANDA® nursing diagnoses get updated
all the time, so look at your book and pick an up-to-date respiratory related diagnosis
that would fit in here. There should be several. So, just using this as an example, we’re going
to go with “Not enough oxygen.” Okay, then the next thing you’ll do is figure
out what the “related-to” factor is. What’s causing this to happen? What’s the underlying pathophysiology? So for this example pneumonia care plan, we’re
going say that the related-to factor is increased mucous production. Because our example patient has a productive
cough, we know there is a lot of mucous gunkied up in there. And now, we’ll list the “as evidenced by”
symptoms. So this mucous production and decreased oxygenation
is evidenced by, or SHOWN by, just like I said, that productive cough and mucous production,
our patients oxygen saturation is 88%, their PaCO2 is 47mmHg, and the patient reports feeling
fatigued. So that gives us our entire nursing diagnosis
for our pneumonia care plan: Not enough oxygen (remember, that’s NOT a real nursing diagnosis!)
r/t increased mucous production aeb a productive cough, oxygen saturation of 88%, PaCO2 of
47mmHg, and the patient reports she feels fatigued. And now, we’ll move onto the next part of
the pneumonia care plan: the PLANNING column. So this is where you will write your patient
goals or the outcomes you hope they will achieve. And you’ll need to make sure they are SMART
goals, and that they are written as what the patient will do. And if you need a refresher on how to write
SMART patient goals, you’ll definitely want to check out the How To Write Care Plan video
that I’ve got for you. I’ll walk you through the SMART patient goals
framework in that video. So, we’ll start our patient goal with, “The
patient will…” and then we’ll write what we want them to achieve to help improve. So for this example pneumonia care plan, we’ll
say that our goal is, “The patient will have a blood oxygen saturation of at least 95%
by discharge. This goal follows the SMART framework, because
it’s specific, measurable, achievable, relevant and time-bound, and it is patient centric
because we have written it as what the PATIENT will do. And now that we have our goal, we can come
up with a plan to make it happen. And that is your nursing interventions. So for this pneumonia care plan example, we
want to solve the underlying problem with our nursing interventions: the low oxygen
and the mucous production. So if we solve that, our patient should be
able to have a higher oxygen saturation, because in this example, we’ll just say they don’t
have any other conditions. So, some great nursing interventions that
we could do to help increase their oxygen and decrease their mucous build up in the
lungs, are: “The nurse will encourage the patient to drink more fluids to thin mucous
secretion,” “The nurse will educate the patient on controlled coughing and abdominal breathing
exercises to expel mucous and promote oxygenation,” “The nurse will assess and document the patients
vital signs at least every 4 hours,” “The nurse will administer oxygen as prescribed.” And for most nursing schools, they’ll want
you to find an evidenced based rationale for each nursing intervention you use. So go through your textbook and find where
they talk about the disorder or about the intervention you choose, and figure out why
that nursing intervention is important. And finally, the last part of the pneumonia
care plan, you’ll need to evaluate your patients progress. Did they meet that goal or not? If they did meet their goal, you will need
to set a new goal and do this whole process over again with a brand new goal. If they didn’t meet their goal, write down
what changes need to be made in order to help them get there. So with this example pneumonia care plan,
if our patient didn’t meet their goal of having an oxygen saturation of at least 95%, then
we would write what we need to change in the care plan to make that happen next time, things
like: “Meet with the healthcare team to determine the best course of action.” “Continue to assess the patient’s vital signs
and lung sounds,” or “Educate the patient on the importance of adhering to nursing interventions.” So if the goal was not met, make sure you
give some recommendations to help your patient meet that goal. And that is your sample pneumonia care plan! I hope this helped you understand nursing
care plans a bit better. And if you want more sample care plans, you
will definitely want to jump into the NursingSOS Membership Community where we’ve got a ton
of them for you. And of course, if you liked this video, write
LOVE in the comments below to let me know, hit that like button, and make sure you subscribe
and hit the bell so you never miss out on a future video. Thank you so much for watching, friend, now
go become the nurse that God created only YOU to be. And I’ll see you right back here next time
on the nursing school show, take care.

2 Comments

  • Reply NursingSOS September 6, 2018 at 10:57 pm

    Make sure to download the free nursing care plan template + sample care plans here >> http://bit.ly/nursingsos5

  • Reply Harshit Bhati January 23, 2019 at 2:18 pm

    Niceee

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