Pneumonia Nursing Care Plans

ASSESSMENT OBJECTIVES NURSING RATIONALE EXPECTED OUTCOMES

INTERVENTIONS
 Flushed Skin Short term: After 4° of
1. Establish Rapport 1. To gain trust and
Short term:
 Skin Warm to Touch 2. Monitor VS q 4°. have a nurse
NI, the pt’s temperature
3. Provide TSB as a patient relationship After 4° of NI, the pt’s
 Temperature Higher will drop from 38.4 °C to 37
measure. 2. To establish baseline temperature shall drop from
than 37.6C °C
4. Instruct SO to data of the pt’s 38.4 °C to 37.4 or lower
 Rales provide with loose 3. To lower pt’s °C.
 Dehydration Long term: clothing. temperature
 Irritability 5. Assess skin 4. To release heat and
Long term:
After 2-3 days of NI, the temperature and to provide comfort
patient will be free from color. 5. Warm, dry, flushed
6. Monitor WBC count. skin may indicate a After 2-3 days of NI, the
hyperthermia.
7. Encourage fluid fever. patient shall be free from
intake orally or 6. eucocytes indicate hyperthermia.
intravenously as an inflammatory
ordered. and infectious
8. Measure intake and process presence.
output. 7. Replaces fluid lost by
insensible loss and
perspiration.
8. Determine fluid
balance and need
to increase fluid
intake.