eNursing Care Plan 27-1

Patient With Pneumonia

Nursing Diagnosis*1

Impaired gas exchange related to fluid and exudate accumulation at the capillary-alveolar

membrane as evidenced by decreased breath sounds, abnormal arterial blood gas levels,

abnormal chest x-ray, restlessness, and confusion

Patient Goals

1. Maintains adequate alveolar O2-CO2exchange

2. Clears lungs of fluids and exudates
Outcomes (NOC) Interventions (NIC) and Rationales
Respiratory Status: Gas Respiratory Monitoring
Exchange
Auscultate breath sounds, noting areas of decreased or absent
PaO2 ___ ventilation, and presence of adventitious sounds to obtain ongoing
data on patient’s response to therapy.
PaCO2 ___
Monitor rate, rhythm, depth, and effort of respirations to determine
Arterial pH ___ respiratory status.
O2 saturation ___ Monitor for increased restlessness, anxiety, and air hunger to detect
Chest x-ray findings ___ increasing hypoxemia.
Monitor patient’s ability to cough effectively to promote secretion
removal.
Monitor patient’s respiratory secretions to detect purulent sputum
Measurement Scale or hemoptysis.
1 = Severe deviation from
normal range
2 = Substantial deviation from
normal range Oxygen Therapy
3 = Moderate deviation from Administer supplemental O2 as ordered to promote adequate
normal range oxygenation.
4 = Mild deviation from normal Set up O2 equipment and administer through a humidified system to
range prevent drying of the respiratory tract.
5 = No deviation from normal Monitor the effectiveness of O2 therapy (e.g., pulse oximetry, ABGs)

1*
Nursing diagnoses listed in order of priority.

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 eNursing Care Plan 27-2

range to evaluate patient response to therapy.

Dyspnea at rest ___
Dyspnea with mild exertion ___
Restlessness ___
Monitor for skin breakdown from friction of O2 device.
Monitor patient’s anxiety related to need for O2 therapy to provide
explanations and reassurance.
Periodically check O2 delivery device to ensure that the prescribed
concentration is being delivered.

Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None

Nursing Diagnosis

Ineffective breathing pattern related to inflammation and pain as evidenced by dyspnea,

tachypnea, nasal flaring, altered chest excursion

Patient Goal

Demonstrates effective respiratory rate, rhythm, and depth of respirations

Outcomes (NOC) Interventions (NIC) and Rationales

Respiratory Status: Ventilation
Respiratory rate ___
Respiratory rhythm ___
Tidal volume ___
Depth of inspiration ___
Percussed sounds ___
Measurement Scale
1 = Severe deviation from
normal range
2 = Substantial deviation from
Ventilation Assistance
Monitor respiratory and oxygenation status to detect change in
status.
Position to minimize respiratory efforts (i.e., elevate the head of the
bed and provide overbed table for patient to lean on) to reduce
work of breathing and oxygen needs.
Encourage slow, deep breathing, turning, and coughing to promote
effective breathing pattern.
Monitor for respiratory muscle fatigue to provide additional support
if needed.
Auscultate breath sounds, noting areas of decreased or
absent ventilation, and presence of adventitious sounds.
Assist with incentive spirometer, as appropriate, to promote alveolar
ventilation.

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 eNursing Care Plan 27-3

normal range Administer medications (e.g., bronchodilators and inhalers) that

promote airway patency and gas exchange.
3 = Moderate deviation from
normal range
4 = Mild deviation from normal
range
5 = No deviation from normal
range

Dyspnea at rest ___

Atelectasis ___
Asymmetrical chest expansion ___
Chest retraction ___

Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None

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 eNursing Care Plan 27-4

Nursing Diagnosis

Acute pain related to inflammation and ineffective pain management and/or comfort measures

as evidenced by possible presence of pleural friction rub, shallow respirations, and patient report

of pleuritic chest pain

Patient Goal

Reports control of pain following relief measures

Outcomes (NOC) Interventions (NIC) and Rationales

Pain Control
Reports pain is controlled ___
Describes causal factors ___
Uses nonanalgesic relief measures
___
Uses analgesics as recommended
___
Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated
Pain Management
Perform a comprehensive assessment of pain to include location,
characteristics, onset/duration, frequency, quality, intensity or
severity of pain, and precipitating factors to determine appropriate
interventions.
Encourage patient to monitor own pain and to intervene
appropriately to allow independence and prepare for discharge.
Teach use of nonpharmacologic techniques (e.g., relaxation, guided
imagery, music therapy, distraction, and massage) before, after,
and–if possible–during painful activities; before pain occurs or
increases; and along with other pain relief measures to relieve
pain and reduce the need for analgesia.
Use pain control measures before pain becomes severe because mild
to moderate pain is controlled more quickly.
Medicate before an activity to increase participation, but evaluate
the hazard of sedation to help minimize pain that will be
experienced.

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 eNursing Care Plan 27-5

eNursing Care Plan 27-2

Patient After Thoracotomy

Nursing Diagnosis*2

Ineffective breathing pattern related to pleural fluid collection, presence of thoracotomy

incision, chest tube placement, pain, and body position as evidenced by shallow respirations,

altered chest excursion, and/or dyspnea

Patient Goal

Demonstrates an effective rate, rhythm, and depth of respirations

Outcomes (NOC) Interventions (NIC) and Rationales

Respiratory Status
Respiratory rate ___
Respiratory rhythm ___
Depth of inspiration ___
Achievement of expected incentive
spirometer ___
Auscultated breath sounds ___
O2 saturation ___
Measurement Scale
1 = Severe deviation from
normal range
2 = Substantial deviation from
normal range
3 = Moderate deviation from
normal range
4 = Mild deviation from normal
Ventilation Assistance
Assist with frequent position changes to promote lung expansion and
drainage of secretions and/or fluid.
Encourage slow deep breathing, turning, and coughing to facilitate
lung expansion.
Assist with incentive spirometer to provide visual feedback to the
patient on effectiveness of respirations.
Auscultate breath sounds, noting areas of decreased/absent
ventilation and presence of adventitious sounds to determine
improvement or worsening of respiratory status.
Initiate and maintain supplemental O2 as prescribed to meet O2
needs.
Administer appropriate pain medication to prevent hyperventilation
or hypoventilation.
Position to minimize respiratory efforts (i.e., elevate the head of the
bed and provide overbed table for patient to lean on) Ambulate
three or four times a day to promote deep breathing and lung
reexpansion.

2*
Nursing diagnoses listed in order of priority.

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 eNursing Care Plan 27-6

range
5 = No deviation from normal
range

Nursing Diagnosis

Risk for infection related to tissue injury, placement of chest tubes

Patient Goals

1. Experiences no indication of infection

2. Incision and stab wounds heal by first intention
Outcomes (NOC) Interventions (NIC) and Rationales
Infection Severity Infection Protection
Purulent drainage ___ Monitor for systemic and localized signs and symptoms of infection
to enable early detection and treatment.
Purulent sputum ___
Inspect condition of surgical incisions/wounds to detect early signs
Chest x-ray infiltration ___ of infection.
Fever ___ Change thoracotomy dressings (as ordered by the health care
Pain/tenderness ___ provider) using strict sterile aseptic technique to minimize risk of
infection
White blood cell count elevation
___ Encourage increased mobility and exercise to increase circulation
and promote healing.
Sputum culture colonization ___
Obtain blood, wound, and/or urine samples for cultures as needed
Wound site culture colonization to identify causative agents and effective antibiotics.
___

Measurement Scale Tube Care: Chest

1 = Severe Document bubbling of the suction chamber of the chest tube
drainage system and tidaling in water-seal chamber to ensure
2 = Substantial adequate function of the chest tube.
3 = Moderate Ensure that all tubing connections are securely attached and taped
4 = Mild to prevent air leaks.

5 = None Keep the drainage container below chest level to facilitate drainage.
Observe volume, color, and consistency of drainage from lung, and
record appropriately to detect infection.
Send questionable tube drainage for culture and sensitivity (e.g.,
cloudy or purulent drainage, patient with high temperature) to

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eNursing Care Plan 27-7

identify possible infecting organism.

Cleanse skin around the tube insertion site with appropriate
antiseptic to decrease exposure to pathogens.
Assist patient to cough, deep breathe, and turn every 2 hours to
mobilize secretions and prevent pneumonia.
Change dressing around chest tube every 48 to 72 hours as needed
to monitor site and provide protection.
Change chest tube drainage bottles or multichamber drain devices,
as needed to avoid overfilling or to control infection.

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