NURSING CARE PLAN

ASSESSMENT
Subjective:

Objective:
T= 38.2
PR= 112
RR= 25
BP= 100/60
Flushed skin
Weak
Dypneic
Anxious
Easy fatigability
(+) crackles,
wheezing
(+)chest pain
(+) dullness on
percussion
of affected
area
cough with blood
tinged
sputum

DIAGNOSIS

PLAN OF CARE

Risk for (spread)

of infection
related to
bacterial
organism present
in the lung
parenchyma as
evidenced by:
accumulation
Of secretion in the
lungs.

To be able to treat
current infection
without
complication as
evidence by:
To identify
interventions to
prevent/ reduce
the risk of
secondary
infection
To be able to
manifest
improvement in
respiratory
function.

INTERVENTION

Monitor Vital signs closely

every 4hours especially
during initiation of therapy
Continuously observe for
sudden changes in condition
such as increasing chest
pain, sensorium and color of
sputum
Change position frequently
every 2 hours and provide
good pulmonary hygiene
Institute isolation precaution
as appropriate.
Administer anti pyretic and
anti infective medication as
ordered.
Demonstrate/encourage
good hand washing
technique
Use incentive spirometer 510 breaths if tolerated
Check ABG and oximetry
reading
Encourage adequate rest
balanced with moderate
activity.
Monitor effectiveness of
anti-infective therapy

EVALUATON
Client was able to
treat/control spread
of infection as
evidenced by:
Vital signs returning
to normal range
Absence of chest
pain
Blood gases within
normal range
Demonstrate
awareness of
infection control such
as proper hand
washing and disposal
of secretions
WBC within normal
limits
Negative sputum
culture

PATIENT TEACHING

Medication Management

Remind patient not to miss dose and take the full course of anti-infective treatment even if feeling better to
prevent antibiotic resistance
Instruct to take anti-infective medication with full glass of water with meals

Home Care Management

Encourage to drink at least 2 liters of water per day which promotes hydration, helps thin and loosen up
mucus secretions.
Wash your hands with soap and water or use an alcohol-based hand rub to prevent spread of infection
Cough or sneeze into a tissue or into your elbow or sleeve. Dispose tissue properly.
Instruct client to notify family doctor or health care provider for signs and symptoms of reoccurrence such as
chills and fever, dyspnea, cough with increased sputum production.
Avoid persons with upper respiratory tract infection
Instruct the client to get prompt treatment for early signs of infection
Suggest client to get flu and pneumonia vaccines

Lifestyle Changes

Instruct client to stop smoking and avoid second hand smoke.

Avoid excessive alcohol which lowers resistance to infection.
Stay active. Even a little exercise may help your lungs fight off infections in the future.
Eat a well balanced diet

SCENARIO
Mrs. M, 86 years old has been admitted to the hospital with the diagnosis of pneumonia. She has been staying at
the East coat Community Nursing Home for the past 3years. She had been independent and can do mosy of her
daily activities, until one day PTA, Mrs. M complained of shortness of breath accompanied by fever of 38deg and
mucle weakness which ld to her admission. Mrs. M was put on respiratory isolation to prevent further spread of
infection.

Question:
The physician ordered Ampicillin 500mg every 8 hours for clients pneumonia. The drug available is Ampicillin
780mg/5ml(?). How much will you administer?