Pneumonia documentation/intervention
What are your assessments? What are your interventions? Whatever you do for the patient make sure you record in their documentation.
In an inpatient setting, monitor their vitals every 4 hours or more if it becomes unstable or if anything changes temperature heart rate respiratory rate blood pressure.
If there are any changes in the things mentioned above, notify the physician, and document that you notified them.
Check your patient's pulse ox, vital signs, ABGS. Did the doctor order oxygen rate, time started, delivery device all need to be documented.
It's important to monitor fluid balance record intake and output q 4 hours if any significant imbalances occur notify the physician and what you were doing in the meantime to help the patient.
Try to markdown times of specimen collections and when antibiotics start obviously with drug names dosage ECT.
Remember if it is a new IV antibiotic record if the patient has an allergic reaction or no signs of allergic reaction.
What are you doing to help with clearing secretions are you elevating the head of the bed and couraging frequent coughing and deep breathing, recommend chest pt...?
Patients may be too weak to eat without help and may require assistance at mealtimes from dietary and aides to get the best nutrition to aid healing.
Encourage activity. Can you at least get them up sitting or up into a chair?
Last but not least document what you teach are you teaching them the drugs that they're taking how to cough and deep breathe good hygiene practices signs and symptoms to report activity and rest these are all things that people sometimes need refreshers on especially when they're sick.
