The RN is updating the plan of care for a patient with a medical diagnosis of pneumonia. The patient was admitted yesterday, with a respiratory rate of 28, crackles in the right middle and lower lobes, a dry cough, and oxygen saturation of 90% on room air. The patient was using a bedside commode until earlier today, because of shortness of breath with any activity. The following nursing diagnoses and outcomes were included in the plan of care at the time of admission:
Nursing diagnosis: Impaired gas exchange related to ventilation perfusion imbalance as evidenced by oxygen saturation of 90%.
Expected outcome: Patient will demonstrate oxygen saturation greater than 95% within 24 hours.
Nursing diagnosis: Ineffective airway clearance related to retained secretions as evidenced by crackles in the right middle and lower lobes.
Expected outcome: Patient will demonstrate clear breath sounds in bilateral upper and lower lobes within 24 hours.
Nursing diagnosis: Ineffective breathing pattern related to hyperventilation as evidenced by shortness of breath and RR of 28 breaths per minute.
Expected outcome: Patient will demonstrate RR between 12-20 breaths per minute within 24 hours.
Nursing diagnosis: Activity intolerance related to imbalance between oxygen supply and demand as evidenced by shortness of breath when ambulating.
Expected outcome: Patient will demonstrate no shortness of breath with ambulation within 24 hours.
The patient has been receiving treatment for the past 24 hours, and currently has a respiratory rate of 20 breaths per minute, crackles in the right lower lobe, breath sounds clear in all other lobes, oxygen saturation of 94% on 2 liters of oxygen via nasal cannula, and denied shortness of breath when ambulating to the bathroom an hour ago.