LAGUARDIA COMMUNITY COLLEGE
CITY UNIVERSITY OF NEW YORK
DEPARTMENT OF NATURAL & APPLIED SCIENCE
PRACTICAL NURSING PROGRAM
DOCUMENTION OF THE NURSING PROCESS
CLIENT’S INTIALS:
STUDENT NAME: MANOLITO GULLA___________________ DATE: ____11/11/06____________
MEDICAL DIAGNOSIS:
_PNEUMONIA_______________________
INSTRUCTOR
VALERIE TAYLOR-HASLIP, MSN,FNP
CLIENT CARE OBJECTIVE (S):TO RELIEVE CLIENT’S SYMPTOMS THROUGH APPROPRIATE ANTIBIOTIC THERAPY AND ADMINISTRATION OF OXYGEN.
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ASSESSMENT
(SUBJECTIVE/OBJECTIVE)
Data Collection
2-day history of chest pain,
weakness, and fever
At risk for pneumonia
Long history of alcohol abuse
CLIENT’S PROBLEM (S)/NEED(S)
(USE NURSING DIAGNOSIS
STATEMENTS)
Ineffective Airway Clearance related to
tracheobronchial infection as evidenced
by great respiratory distress, difficulty
in breathing and extreme anxiety.
Risk for ineffective gas exchange
related to lung pathology.
CLIENT SHORT TERM
GOAL/OUTCOME
(PLANNING)
Client will maintain patent
airway as evidenced by
easy and unlabored
respirations.
NURSING
INTERVENTION
(APPROACH)/ (ACTION)
SCIENTIFIC RATIONALE
FOR
NURSING INTERVENTION
Elevate HOB to put client in an
orthopneic position.
Proper positioning makes the client
more comfortable and helps to make
breathing easier.
Instruct and assist client to turn,
cough, and deep breathe every 2
hours.
TCDB assists in the loosening and
expectoration of mucous.
Promote optimum level of activity
Activity leads to the best possible
lung expansion.
Monitor for increasingly labored
respirations.
If client exhibits increasing
difficulty in breathing, give oxygen
by mask or cannula.
Place pillow lengthwise under the
back.
This encourages fuller chest
expansion.
Place a blanket around the
shoulders if the client has chills.
A blanket provides comfort and
warmth, minimizing energy
expenditure.
Keep the client’s bed dry.
Wet bed linens can chill the client.
Heavy smoker for 50+ years
In great respiratory distress
Difficulty in breathing
Risk for activity intolerance related to
reduced lung capacity.
Extremely anxious
LAGUARDIA COMMUNITY COLLEGE
CITY UNIVERSITY OF NEW YORK
DEPARTMENT OF NATURAL & APPLIED SCIENCE
PRACTICAL NURSING PROGRAM
DOCUMENTION OF THE NURSING PROCESS ( Con’t)
ASSESSMENT
(SUBJECTIVE/OBJECTIVE)
Data Collection
CLIENT’S PROBLEM (S)/NEED(S)
(USE NURSING DIAGNOSIS
STATEMENTS)
CLIENT SHORT TERM
GOAL/OUTCOME
(PLANNING)
NURSING
INTERVENTION
(APPROACH) (ACTION)
SCIENTIFIC RATIONALE
FOR
NURSING INTERVENTION
Assess the client’s vital signs at
least every 4 hours.
Frequent monitoring is necessary to
allow for prompt detection and early
intervention if problems arise.
Maintain the IV site or heparin
lock.
The client is probably receiving
antibiotics.
Encourage the client to cough and
to expectorate secretions while
splinting the chest.
Keep the lungs as free of secretions
as possible. Splinting the chest helps
to relieve the discomfort of
coughing.
Encourage deep breathing.
Aerosolized treatments or
incentive spirometry may be
prescribed.
The lungs must be expanded as
much as possible.
Measure intake and output and
daily weights, if ordered.
Client may have edema. He may
need TPN to maintain hydration and
nutrition.
Give small amounts of fluids
frequently.
Fluids help to encourage hydration.
Provide frequent mouth care; put
water soluble lubricant on the
client’s lips.
Client has probably been breathing
through the mouth and made it dry.
Encourage client to move about.
Movement causes lung expansion.
Keep the client’s surroundings
quiet.
Rest promotes healing.