Possibly evidenced by
Restlessness and changes in mentation
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Gas Exchange
Demonstrate improved ventilation and oxygenation of tissues by ABGs within client’s acceptable range and absence of symptoms of respiratory distress.
Participate in actions to maximize oxygenation.
Nursing intervention with rationale:
1. Assess respiratory rate, depth, and ease.
Rationale: Manifestations of respiratory distress are dependent on, and indicative of, the degree of lung involvement and underlying general health status.
2. Observe color of skin, mucous membranes, and nailbeds, noting presence of peripheral cyanosis (nailbeds) or central cyanosis (circumoral).
Rationale: Cyanosis of nailbeds may represent vasoconstriction or the body’s response to fever or chills; however, cyanosis of earlobes, mucous membranes, and skin around the mouth (“warm membranes”) is indicative of systemic hypoxemia.
3. Assess mental status.
Rationale: Restlessness, irritation, confusion, and somnolence may reflect hypoxemia or decreased cerebral oxygenation.
4. Monitor heart rate and rhythm.
Rationale: Tachycardia is usually present as a result of fever and dehydration, but may represent a response to hypoxemia.
5. Monitor body temperature, as indicated. Assist with comfort measures to reduce fever and chills, such as addition or removal of bedcovers, comfortable room temperature, and tepid or cool water sponge bath.
Rationale: High fever, common in bacterial pneumonia and influenza, greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation.
6. Maintain bedrest. Encourage use of relaxation techniques and diversional activities.
Rationale: Prevents exhaustion and reduces oxygen consumption and demands to facilitate resolution of infection.
7. Elevate head and encourage frequent position changes, deep breathing, and effective coughing.
Rationale: These measures promote maximal inspiration and enhance expectoration of secretions to improve ventilation.
8. Assess level of anxiety. Encourage verbalization of concerns and feelings. Answer questions honestly. Visit frequently and arrange for significant other (SO) and visitors to stay
with client as indicated.
Rationale: Anxiety is a manifestation of psychological concerns and physiological responses to hypoxia. Providing reassurance and enhancing sense of security can reduce the psychological
component, thereby decreasing oxygen demand and adverse physiological responses.
9. Observe for deterioration in condition, noting hypotension, copious amounts of pink or bloody sputum, pallor, cyanosis, change in level of consciousness, severe
dyspnea, and restlessness.
Rationale: Shock and pulmonary edema are the most common causes of death in pneumonia and require immediate medical intervention.