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:
- Normal gas exchange.
- Effective airway clearance.
- Intake and output balance.
- Adequate nutritional intake.
- Body temperature within normal limits.
- Increase family knowledge.
- Anxiety resolved.