SCENARIO:

A 15-year-old male patient arrives at the emergency room presenting with symptoms suggestive of community-acquired pneumonia. He
subjectively complains of a persistent cough that is "keeping me up at night' and describes his chest pain as "sharp and worsening with deep
breaths. Objective data reveals diminished breath sounds and crackles upon auscultation of the left lower lung fields, along with increased work
of breathing characterized by accessory muscle use and nasal flaring. The patient appears pale and sweaty, demonstrating signs of easy
fatigability, and exhibits limited physical movement due to discomfort and respiratory distress. Vital signs indicate a temperature of 38.2°C,
heart rate of 110 bpm, respiratory rate of 24 breaths/min, and oxygen saturation of 92% on room air. Chest X-ray confirms the presence of
patchy infiltrates consistent with pneumonia. The plan includes initiating antibiotic therapy, pain management, and close monitoring of
respiratory status, with admission for further management and observation.

Nursing Care Plan (NCP) for Community-Acquired Pneumonia

Patient: 15-year-old male presenting with symptoms suggestive of Community-Acquired Pneumonia
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objective Data: - Impaired Gas The plan includes - Administer oxygen -Oxygen therapy - Improved oxygenation
- Diminished Exchange related to initiating antibiotic therapy to maintain improves oxygenation status as evidenced by
breath sounds in alveolar-capillary therapy, pain oxygen saturation and prevents normal respiratory rate
left lower lung membrane changes management, and above 92% hypoxemia(deficient and oxygen saturation
fields secondary to close monitoring of oxygenated blood) above 92%
- Presence of pneumonia. respiratory status,
crackles in left - Ineffective with admission for - Reduced pain intensity
lower lung fields Breathing Pattern further management -Assess pain intensity -Analgesics relieve pain and improved ability to
- Increased work related to respiratory and observation. and administer and promote patient take deep breaths
of breathing, distress and analgesics as comfort
accessory muscle increased work of prescribed
use, nasal flaring breathing - Restoration of effective
- Pale and sweaty - Risk for Decreased -Encourage and assist -Breathing exercises breathing pattern with
appearance Cardiac Output with coughing and facilitate airway decreased work of
- Limited physical related to fever and deep breathing clearance and improve breathing
movement due to tachycardia exercises ventilation
discomfort and - Maintenance of
respiratory distress -Monitor vital signs and -Vital signs monitoring adequate cardiac output
- Vital Signs: respiratory status detects changes in the with resolution of fever
 Temperature: closely patient's condition and stabilization of heart
38.2°C rate
- Heart Rate: 110 -Administer respiratory -Respiratory
bpm medications as medications help in
- Respiratory Rate: prescribed bronchodilation and
24 breaths/min - secretion clearance
Oxygen Saturation:
92% on room air
- Chest X-ray
confirms patchy
infiltrates
consistent with
pneumonia

Subjective Data:
- "keeping me up at
night' and
describes his chest
pain as "sharp and
worsening with
deep breaths

Focus, Data, Action, and Response (FDAR) Chart

Focus Data Action Response

Impaired gas exchange due to
pneumonia
Subjective Data
- he complains of a persistent
cough that is "keeping me up
at night' and describes his
chest pain as "sharp and
worsening with deep breaths
Objective Data
- Administer oxygen therapy
to maintain oxygen saturation
above 92%.
- Monitor respiratory status
closely, including rate, depth,
and effort.
- Position patient in semi-
Fowler's position to improve
- Respiratory rate stabilizes
within normal range.
- Oxygen saturation improves
to >92% on supplemental
oxygen.
- Patient reports decreased
respiratory distress and
improved comfort.
-diminished breath sounds, lung expansion.
crackles, increased work of - Encourage coughing and
breathing, and nasal flaring. deep breathing exercises for
- Vital signs: Temperature secretion clearance.
38.2°C, heart rate 110 bpm,
respiratory rate 24
breaths/min, oxygen
saturation 92% on room air.
- Chest X-ray confirms patchy
infiltrates consistent with
pneumonia