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Bronchopneumonia - Nursing Diagnosis, Interventions and Evaluation

Nursing Diagnosis and Interventions for Bronchopneumonia -

1. Ineffective airway clearance related to accumulation of secretions.

Goal: Airway clearance back effectively.

Outcomes: secretions can come out.

Interventions:
  • Monitor respiratory status every 2 hours, assess the increase in respiratory and abnormal breath sounds.
  • Do suction as indicated.
  • Give oxygen therapy every 6 hours.
  • Create an environment / convenient so patients can sleep.
  • Give a comfortable position for the patient.
  • Monitor blood gas analysis to assess respiratory status.
  • Perform chest percussion.
  • Provide sputum for culture / sensitivity test.


2. Impaired gas exchange related to changes in alveolar capillaries.

Goal: back to normal gas exchange.

Outcomes: The client showed improved ventilation, gas exchange and oxygenation optimally adequately.

Interventions:
  • Observation of level of consciousness, respiratory status, signs cianosis.
  • Give appropriate sleeping position fowler / semi-Fowler.
  • Give oxygen according to the program.
  • Monitor blood gas analysis.
  • Ciprtakan comfortable environment.
  • Help prevent fatigue.


3. Fluid volume deficit related to excessive output.

Goal: Client will maintain normal body fluid.

Outcomes: no sign of dehydration.

Interventions:
  • Record intake and output of fluids (fluid balance).
  • Encourage the mother to continue to provide oral fluid.
  • Monitor fluid balance, mucous membranes, skin turgor, rapid pulse, decreased consciousness, vital signs.
  • Maintain a drip infusion accuracy.
  • Observation of vital signs (pulse, temperature, respiration).


4. Risk for Imbalanced nutrition less than body requirements related to inadequate nutritional intake.

Goal: The nutritional requirements are met.

Outcomes: The client can maintain / improve nutritional intake.

Intervetions:
  • Assess the client's nutritional status.
  • Perform a physical examination of the abdomen (auscultation, percussion, palpation, and inspection).
  • Measure the client's body weight every day.
  • Assess for nausea and vomiting.
  • Give the diet a little but often.
  • Provide food in a warm state.
  • Collaboration with the nutrition team.


5. Increased body temperature related to the infection process.

Goal: There is an increase in body temperature.

Outcomes: Hyperthermia / increase in temperature can be resolved with no infection process.

Interventions:
  • Observation of vital signs.
  • Provide and encourage families to provide water compress on the forehead area and armpits.
  • Involve the family in every action.
  • Give drink orally.
  • Replace wet clothing with sweat.
  • Collaboration with doctors in febrifuge.


6. Knowledge Deficit : parents, about the care of clients related to a lack of information.

Goal: Knowledge parents about the child's illness increased after the act of nursing.

Outcomes: Parents know about the child's illness.

Interventions:
  • Assess the level of parental knowledge about the child's illness.
  • Assess the client's level of parental education.
  • Help parents to develop a plan of nursing care in the hospital such as: diet, rest and activity accordingly.
  • Emphasize the need to protect children ..
  • Explain to the client's family about the definition, causes, signs and symptoms, treatment, and prevention of complications by providing health education.
  • Give parents the opportunity to ask clients about things not yet understood.


7. Anxiety children related to the effects of hospitalization.

Goal: Anxious children is reduced / lost.

Outcomes: The client can be quiet, anxious lost, comfortable feeling fulfilled after the act of nursing.

Interventions:
  • Assess the client's level of anxiety.
  • Encourage the mother / family to give suport to the child by way of the mother is always near to the client.
  • Facilitating a sense of comfort by way of participating mothers caring for their children.
  • Make a visit, contact with clients.
  • Encourage other family visiting clients.
  • Give A toy according client's home.


Evaluation

The evaluation is expected in patients with Brochopneumonia are:
  1. Normal gas exchange.
  2. Effective airway clearance.
  3. Intake and output balance.
  4. Adequate nutritional intake.
  5. Body temperature within normal limits.
  6. Increase family knowledge.
  7. Anxiety resolved.