Nursing Care Plan for Pneumonia
Nursing Diagnosis for Pneumonia
Nursing Diagnosis for Pneumonia
Nursing Interventions for Pneumonia
Pneumonia is an illness that affects one or both lungs and that used to be one of the main causes of death 2 centuries ago. It is caused by microorganisms that attack the tissue from the lungs, causing it to inflammate and leading to a severe condition if the infection is not treated in time.
Viral pneumonia is very common form of pneumonia affecting children, teenagers and the elderly. It can sometimes be mistaken for either the flu or a cold. Viral pneumonia presents the following symptoms: inflammation of the throat, productive or non-productive cough, a swelling in the lymph nodes, chest discomfort during breathing, mild to severe headache and a generalized feeling of fatigue. The cough may or may not produce varying amounts of mucus. You may also experience a mild fever and chills.
Pneumonia
1. Impaired Gas Exchange
2. Ineffective Breathing Pattern
3. Risk for Infection related
4. Ineffective airway clearance
5. Activity Intolerance
Nursng Interventions - Impaired Gas Exchange for Pneumonia:
- Assess the frequency / depth and ease of breathing
Rational: the manifestation of respiratory distress depends on the indication of the degree of lung involvement and general health status.
- Observe the color of skin, mucous membranes and nails. Note the presence of peripheral cyanosis (nail) or central cyanosis.
Rational: nails showed cyanosis vasoconstriction body's response to fever / chills, but cyanosis on the ears, mucous membranes and skin around the mouth indicate systemic hypoxemia.
- Assess mental status.
Rational: nervous irritability, confusion and somnolence may indicate cerebral hypoxia or decreased oxygen.
- Elevate the head and thrust frequently change position, breathe deeply and cough effectively.
Rationale: This action increases the maximum inspiration, increased spending secretions to improve ventilation ineffective.
- Collaboration
Give oxygen therapy correctly.
Rational: to maintain PaO2 above 60 mmHg. Oxygenation provided with a method that provides precise delivery.
Nursing Interventions - Ineffective Breathing Pattern for Pneumonia :
Assess the frequency, depth of breathing and chest expansion
Auscultation of breath sounds
Elevate the head and help change the position
Observation of cough pattern and character of secretions
Encourage / help the patient breathe deeply and cough effectively exercise
Give additional oxygen
Watch the Blood Gas Analysis
Nursing Interventions - Ineffective Airway Clearance for Pneumonia :
- Assess the frequency / depth of breathing and chest movement
Rational: tachypnea, shallow breathing and chest movement was symmetrical often occurs because of discomfort.
- Auscultation of lung area, record the time there's an area of decreased airflow and breath sounds
Rational: decrease in blood flow occurred in the area of consolidation with fluid.
- Teach effective cough techniques
Rational: cough is a natural airway clearance mechanisms for maintaining a patent airway.
- Sucking as indicated
Rational: stimulate coughing or clearing the airway of mechanical noise on the factors that are not able to perform effectively because of a cough or a decreased level of consciousness.
- Give fluids at least
Rational: liquid (especially warm) mobilizing and removing secretions.
- Collaboration with physicians for drug delivery as indicated: mukolitik, ex.
Rational: a tool to reduce bronchial spasms with mobilization of secretions, analgesic given to improve the cough by decreasing the discomfort but should be used carefully, because it can reduce cough effort / suppress breathing.