Here’s your step-by-step guide to writing an AMAZING pneumonia care plan in nursing school.
If you’re struggling with how to write nursing care plans, you will definitely want to watch this video all the way through.
I’ll walk you through, step-by-step, how to write a pneumonia care plan for nursing school, including: pneumonia nursing diagnosis, nursing assessment, signs and symptoms of pneumonia, pneumonia nursing interventions, and the pneumonia nursing care you might provide for your patients with pneumonia.
Thanks for watching this pneumonia care plan video! Now go become a nursing ROCK STAR! 🙂
Want more videos to help you raise your grades + save more time in nursing school?
VIDEO TRANSCRIPT
**This post contains affiliate links. If you decide to purchase a product through using this link, I will receive a small commission at no additional cost to you. Thanks for your support!**
Hey there friend! My name is Christina Rafano from nursingsos.com and in this video 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 you check out the Nursing Care Plan Template video I’ve got for you, that will walk you through how to set up your nursing care plan and go through everything you’ll need to include. And of course, if you want more care plan examples, you’ll definitely want to check out the care plan database that I’ve got for you inside the NursingSOS Membership Community. I’ll put a link in the description below for you to check that out. Now, let’s go through a pneumonia care plan.
Okay, so nursing care plans have 5 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 for this video. There’s a link down below for you to download that. And I also threw in some other sample care plans as well, so definitely check that out!
So, the first column, you’ll write your nursing assessment of your patient with pneumonia. So at clinical, make sure you assess your patient super well and make sure to 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 pieces here. So, if we have a patient with pneumonia, we could say they have a heart rate of 100 beats per minute, a respiratory rate of 20 breaths per minute, an oxygen saturation of 88%, a cough with mucous coming up (so a productive cough), arterial blood gas analysis shows respiratory acidosis with a PaCO2 of 47mmHg, and the patient reports feeling fatigued and out of breath.
So you’ll write all of this in the first column of your pneumonia care plan. And if you want to get fancy, you can break it up into subjective and objective data, too.
Now, you’ll move onto the next column, which is diagnosis. And here is where you’ll bust out your care plan book and choose the best NANDA® nursing diagnosis for your patient. I HIGHLY recommend you snag the Nursing Diagnosis Handbook by Ackley and Ladwig.
This is the nursing care plan book I always recommend to students, it’s a game changer, it basically writes your care plans for you. So if you want to check that out, I’ll put an affiliate link down below in the description, and if you do decide to purchase that book through my link, I will receive a small commission, just a little disclaimer there, so thanks for that, I really appreciate your support, thank you so much.
So you’ll go through the list of NANDA® nursing diagnoses and you’ll pick out the best one that is a priority for your patient. So, as an example for pneumonia, we’ll create a made up nursing diagnosis of “Not enough oxygen,” 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 get updated all the time, so look at your book and pick an up-to-date respiratory related diagnosis that would fit in here. There should be several.
So, just using this as an example, we’re going to go with “Not enough oxygen.”
Okay, then the next thing you’ll do is figure out what the “related-to” factor is. What’s causing this to happen? What’s the underlying pathophysiology? So for this example pneumonia care plan, we’re going say that the related-to factor is increased mucous production. Because our example patient has a productive cough, we know there is a lot of mucous gunkied up in there.
And now, we’ll list the “as evidenced by” symptoms. So this mucous production and decreased oxygenation is evidenced by, or SHOWN by, just like I said, that productive cough and mucous production, our patients oxygen saturation is 88%, their PaCO2 is 47mmHg, and the patient reports feeling fatigued.
So that gives us our entire nursing diagnosis for our pneumonia care plan: Not enough oxygen (remember, that’s NOT a real nursing diagnosis!) r/t increased mucous production aeb a productive cough, oxygen saturation of 88%, PaCO2 of 47mmHg, and the patient reports she feels fatigued.
And now, we’ll move onto the next part of the pneumonia care plan: the PLANNING column. So this is where you will write your patient goals or the outcomes you hope they will achieve. And you’ll need to make sure they are SMART goals, and that they are written as what the patient will do. And if you need a refresher on how to write SMART patient goals, you’ll definitely want to check out the How To Write Care Plan video that I’ve got for you. I’ll walk you through the SMART patient goals framework in that video.
So, we’ll start our patient goal with, “The patient will…” and then we’ll write what we want them to achieve to help improve. 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.
This goal follows the SMART framework, because it’s specific, measurable, achievable, relevant and time-bound, and it is 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 it happen. And that is your nursing interventions. So for this pneumonia care plan example, we want to solve the underlying problem with our nursing interventions: the low oxygen and the mucous production. So if we solve that, our patient should be able to have a higher oxygen saturation, because in this example, we’ll just say they don’t have any other conditions.
So, some great nursing interventions that we could do to help increase their oxygen and decrease their mucous build up in the lungs, are: “The nurse will encourage the patient to drink more fluids to thin mucous secretion,” “The nurse will educate the patient on controlled coughing and abdominal breathing exercises to expel mucous and promote oxygenation,” “The nurse will assess and document the patients vital signs at least every 4 hours,” “The nurse will administer oxygen as prescribed.”
And for most nursing schools, they’ll want you to find an evidenced based rationale for each nursing intervention you use. So go through your textbook and find where they talk about the disorder or about the intervention you choose, and figure out why that nursing intervention is important.
And finally, the last part of the pneumonia care plan, you’ll need to evaluate your patients progress. Did they meet that goal or not? If they did meet their goal, you will need to set a new goal and do this whole process over again with a brand new goal. If they didn’t meet their goal, write down what changes need to be made in order to help them get there.
So with this example pneumonia care plan, if our patient didn’t meet their goal of having an oxygen 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: “Meet with the healthcare team to determine the best course of action.” “Continue to assess the patient’s vital signs and lung sounds,” or “Educate the patient on the importance of adhering to nursing interventions.”
So if the goal was not met, make sure you give some recommendations to help your patient meet that goal.
And that is your sample pneumonia care plan! I hope this helped you understand nursing care plans a bit better. And if you want more sample care plans, you will definitely want to jump into the NursingSOS Membership Community where we’ve got a ton of them for you.
And of course, if you liked this video, write LOVE in the comments below to let me know, hit that like button, and make sure you subscribe and hit the bell 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.
And don’t forget to SUBSCRIBE to our YouTube channel and HIT THE BELL so you never miss out on any nursing school tips or resources.
Thanks for being all around amazing, my friend! Now go become the nurse that God created ONLY YOU to be. 🙂
