Nursing Care Plan Pneumonia
Nursing Care Plan Pneumonia
1. Breath Pattern ineffectiveness associated with pulmonary infection
Characteristics:
Cough (both productive and non productive), shortness of breath, Tachipnea, breath sounds limited, retracted, fever, diaporesis, ronchii, Cyanosis, leukocytosis.
Destination:
Children will experience breathing pattern characterized by effective:
- The sound is clean and lung breath the same on both sides
- Within the limits of body temperature from 36.5 to 37.2 OC
- The rate of breathing in the normal range
- There is no coughing, Cyanosis, retracted and diaporesis
Intervention
* Conduct assessments every 4 hours of respiration rate, temperature, and signs of airway effectively.
R: Evaluation and reassessment of the actions that will / have been given.
* Perform a scheduled chest Phisioterapi
R: Remove the secretion of the airway, preventing obstruction
* Give Oxygen moist, review the effectiveness of therapy
R: Increased lung tissue oxygen supply
* Give appropriate antibiotics and antipyretics order, review the effectiveness and side effects (rash, diarrhea)
R: Eradication of the bacteria as a factor of disturbance causa
* Perform a gradual suction
R: Helping clean the airway
* Record the results of Pulse Oximeter when installed, every 2 – 4 hours
R: Evaluation of therapeutic success periodic / health team action.
2. Fluid Volume Deficit related to the reduction in fluid intake
Characteristics:
Loss of appetite / drinking, lethargy, fever., Vomiting, diarrhea, dry mucous membranes, poor skin turgor, decreased urine output.
Destination:
Children get an adequate amount of fluid indicated by:
* Adequate Intake, either oral or Intra Venous
* No adan lethargy, vomiting, diarrhea
* Body temperature in normal
* Urine output adequate
Intervention:
* Note the intake and output
R: Evaluation strict intake and output needs
* Review and record the temperature every 4 hours, signs of fluid and conditions devisit Intra Venous line
R: Convincing fluid fulfillment
* Perform mouth care every 4 hours
R: Increasing the clearance sal indigestion, increased appetite / drinking
Other diagnosis:
1. Changes Nutrition: Less than needs associated with anorexia, vomiting, increased calorie consumption secondary to infection
2. Change of comfort associated with headache, chest pain
3. Activity intolerance related to respiratory distress, latergi, decreased intake, fever
4. Anxiety associated with hospitalisasi, respiratory distress
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