Nursing Care Plan

Patient Name: Emily Carter Age: 78 Medical Diagnosis: Pneumonia Assessment: - Patient presents with a productive cough, shortness of breath, and a fever of 38.5°C. - Medical history includes hypertension and a recent fall. Identified Nursing Problem: Impaired gas exchange related to pneumonia. Goals/Outcomes: - Patient will demonstrate improved respiratory function, as evidenced by a respiratory rate within normal limits and oxygen saturation above 90% within 48 hours. - Patient will be afebrile within 72 hours. Interventions: 1. Administer oxygen via nasal cannula at 2L/min, as prescribed. 2. Encourage deep breathing and coughing exercises every 2 hours. 3. Monitor vital signs, including respiratory rate, oxygen saturation, and temperature, every 4 hours. Evaluation: The patient's respiratory rate has decreased from 32 breaths per minute to 24 breaths per minute, and oxygen saturation has improved from 88% to 94% on 2L of oxygen. The patient remains febrile. The goals are partially met. Continue interventions and monitor for further improvement. The patient will be reassessed on 2 November 2024.