Christina Rafano walks through a complete pneumonia care plan using the five-step nursing process: assessment, diagnosis, planning, implementation, and evaluation. She shows how to document vital signs and ABG results, write a NANDA diagnosis with problem and related factors, set a SMART patient goal, and list evidence-based interventions like fluid intake and oxygen administration.
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Hey there friend. My name is Christina Rafano from nursingschoolofsuccess.com and in this video today 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 that you check out the nursing care plan template video that I've got for you that will walk you through how to set up your nursing care plan and go through everything that you'll need to include. And of course, if you want more care plan examples, you will definitely want to check out the care plan database that I've got for you inside of the nursing SOS Membership community. I will put a link down below in the description of this video for you to check that out if you think it will be helpful for you. Now let's go through a pneumonia care plan. Okay, so nursing care plans have five 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 this video. There's a link down below in the description for you to download that if you want to. And I also threw in some sample care plans as well for you in there. So definitely check that out. So the first column of your care plan, you'll write your nursing assessment of your patient with pneumonia. So at clinical, make sure that you assess your patient super well, make sure that you 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 points here. So if we have a patient with pneumonia, we could say that they have a heart rate of 100 beats, perfect minute, a respiratory rate of 20 breaths per minute, an oxygen saturation of 88%, a cough with mucus coming up. So that would be a productive cough. Arterial blood gas analysis showing respiratory acidosis with a Paco 2 of 47 millimeters mercury. And that patient reports feeling fatigued and out of breath. So for example, you'll write all of that into your first column of your pneumonia care plan. And if you want to get all fancy with it, you can break it up into subjective and objective objective data as well too. Now you'll move into the next column, which is the diagnosis part, and here you'll bust out your nursing care plan book and choose the best NANDA nursing diagnosis for your patient. Now, I highly recommend that you snag the Nursing Diagnosis Handbook by Ackley and Ladwig. This is the nursing care plan book that I always Recommend to students it's a game changer for you. It basically writes your care plans for you. So if you want to check that out, I will put an affiliate link down below this video in the description. And if you do decide to purchase that book through my link that I provided for you, I will receive a small commission. Just a little disclaimer here, so thank you so much for that. Of course I'm never going to recommend anything that I don't absolutely love and hold dear to my heart. So you can be confident that it's a game changer for you. So you'll go through that list of NANDA nursing diagnosis and you'll pick the best one that's a priority for your patients. So as an example for pneumonia, we'll just create a made up nursing diagnosis of not enough oxygen. Now 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 are updated all the time. So look at your book. Pick an up to date respiratory related diagnosis that would fit in here with pneumonia. There should be several in there. You can so just using this as an example, we're going to go with not enough oxygen for this patient. Okay then the next thing you need to figure out is what the related two factor is. What's causing this to happen? What's the underlying pathophysiology? So for this example pneumonia care plan we're going to say that that related two factor is increased mucus production. Because our example patient has a productive cough. We know that there is a lot of mucus all gunk eat up in there. And then next we're going to list the as evidenced by symptoms. So this mucus production and decreased oxygenation is evidenced by or shown by just like I said, that productive cough and mucus production. Our patient's oxygen saturation is 88%, their Paco 2 is 47 and the patient reports feeling fatigued. So that gives us our entire nursing diagnosis for your pneumonia care plan. Not enough oxygen. Remember, that's not a real nursing diagnosis related to increased mucus production as evidenced by a productive cough oxygen saturation of 88%, a Paco 2 of 47 and the patient reports she feels fatigued. And now let's move on to the next part of the pneumonia care plan, the planning column. So this is where you would write your patient goals or outcomes you hope they will achieve. And you'll need to make sure that these goals are smart and that they are written as what the patient patient will do. And if you need a refresher on how to write smart patient goals, you'll definitely want to check out the video we've got for you on that how to write care plans video for you. I'll walk you through the smart patient goals framework in that video. So we'll start with our patient goals with the patient will, and then we will write what we want them to achieve to help them improve. So, 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. Now, this goal follows that smart framework because it's specific, it's measurable, it's achievable, it's relevant, and it's time bound. And it's also 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 that happen. Is where your nursing interventions come in. So for this pneumonia care plan example, we want to solve the underlying problem with our nursing interventions, the low oxygen and the mucus production. So if we solve that, our patients should be able to have a higher oxygen saturation because in this example we'll just say that they don't have any other conditions. So some great nursing interventions that we could do to help increase their oxygen and decrease their mucus buildup in the lungs are the nurse will encourage the patient to drink more fluids to kind of thin that mucus out. The nurse will educate the patient on controlled coughing and abdominal breathing to help kind of expel some of that mucus and also to promote more oxygenation. The nurse will assess and document the patient's vital signs at least every four hours or per facility policy. The nurse will administer oxygen as prescribed. And for most nursing schools, they'll want you to find an evidence based rationale for each nursing intervention that you use. So go through your textbook and find where they talk about pneumonia or the other disorders your care plans are on or about the intervention that you choose and figure out why that intervention is important. Now, finally, the last part of the pneumonia care plan, you'll need to evaluate your patient's progress. Did they meet their goal or not? If they did meet their goal, you'll need to set a new goal and do this whole process all over again with that brand new goal. If they didn't meet their goal, write down what changes need to be made in their care plan in order to help them get there and meet their goal. So with this example pneumonia care plan, if our patient didn't meet their goal of having an oxygen and 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 maybe meet with the healthcare team to determine the best course of action, continue to assess the patient's vital signs and their lung sounds, or maybe educate the patient on the importance of adhering to the nursing interventions and that education that we do. So so if the goal was not met, make sure that you give some recommendations to help your patient meet that goal. And that, my friend, is your sample pneumonia care plan. I really hope that this video helps you understand nursing care plans a little bit better. And of course if you want more sample care plans, you will definitely want to jump into the Nursing SOS membership community where I've got a ton of those sample care plans for you. And of course if you liked this video video, write love in the comments below to let me know. Hit that like button. And of course make sure you subscribe and click that little bell icon 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.
