Nursing Care Plan for a Patient with Community-Acquired Pneumonia: Clinical Case

Abstract

Aim. Develop a Nursing Care Plan (NCP) in a clinical case of an adult patient with a diagnosis of Community Acquired Pneumonia (CAP) hospitalized in a Second Level Care Hospital in the city of San Luis Potosí in Mexico. Methodology. A clinical case of a patient with a diagnosis of CAP hospitalized in a Second Level Care Hospital in the city of San Luis Potosí was identified. A nursing assessment was performed using Marjory Gordon’s functional patterns to identify the main nursing diagnoses according to the NANDA, NIC and NOC taxonomy. Diagnoses were prioritized according to Maslow’s pyramid. Results. NCP was developed for diagnoses labeled: a) Impaired gas exchange, b) ineffective airway clearance, and c) Decreased activity tolerance. Conclusion. The care provided by the nursing staff through the nursing care process for patients with CAP allows for a comprehensive approach to provide quality and warmth care; however, it is important to document best practices that the staff has in order to generate evidence based on clinical practice.