Nursing Care Plan

Nursing Care Plan for Pneumonia with Diagnosis Interventions

3 Nursing Diagnosis for Pneumonia

Nursing Care Plan for Pneumonia


Definition

Pneumonia is a breathing (respiratory) condition in which there is an infection of the lung.


Causes

Pneumonia caused by bacteria tends to be the most serious kind. In adults, bacteria are the most common cause of pneumonia.
  • The most common pneumonia-causing germ in adults is Streptococcus pneumoniae (pneumococcus).
  • Atypical pneumonia, often called walking pneumonia, is caused by certain other bacteria.
  • Pneumocystis jiroveci pneumonia is sometimes seen in people whose immune system is not working well.

Many other bacteria can also cause pneumonia.

Viruses are also a common cause of pneumonia, especially in infants and young children.


Signs and Symptoms

Symptoms of pneumonia caused by bacteria usually come on quickly. They may include:
  • Cough.
  • Fever.
  • Fast breathing and feeling short of breath.
  • Shaking and "teeth-chattering" chills. You may have this only one time or many times.
  • Chest pain that often feels worse when you cough or breathe in.
  • Fast heartbeat.
  • Feeling very tired or feeling very weak.
  • Nausea and vomiting.
  • Diarrhea.

Pathogenesis

Pathogenesis of pneumonia include interactions between microorganisms (MO) causes that go through various avenues, with patient endurance. Germs reach the alveoli by inhalation, aspiration of oropharyngeal bacteria, hematogenous spread from another focus of infection, or direct spread from the site of infection. At the lower respiratory tract, the bacteria encounter in the form of immune defense system mukosilier, cellular resistance alveolar macrophages, bronchial lymphocytes and neutrophils. Also humoral immune IgA and IgG from bronchial secretions.
The occurrence of pneumonia depends on the virulence of MO, the ease and extent of endurance.




Assessment - Nursing Care Plan for Pneumonia


A. Subjective Data
  • Sudden onset of fever accompanied by convulsions
  • Clients complained weak
  • Shortness of breath
  • Complaining tired when on the move
  • Insomnia
  • Coughing up phlegm
  • Nausea, vomiting, no appetite
  • Sometimes diarrhea
  • Weight loss

B. Objective Data
  • Cyanosis of the mouth and nose
  • Dry skin with poor turgor
  • Clients look tired
  • Breathing fast (tachypnea) and shallow accompanied nostril
  • Dyspnoea, bronchial breath sounds, crackles.
  • Breathing using accessory muscles
  • Dullness found in percussion
  • Awareness of decreased / lethargy
  • Communication substandard
  • Orientation to person, place and time poor
  • Laboratory results: leukocytosis, increased erythrocyte sedimentation rate, abnormal blood gas analysis
  • Photos chest: there are patches lobe infiltrates.


Nursing Diagnosis for Pneumonia


1.Ineffective Airway Clearance related to inflammation, the accumulation of secretions,
characterized by:
  • Tachypnea / rapid breathing, shallow accompanied nostrils.
  • Bronchial breath sounds, crackles wet, accessory muscle use.
  • Dyspnoea, cyanosis
  • Cough with sputum production.

2.Impaired Gas Exchange related to alveolar capillary membrane changes
characterized by:
  • Dyspnea, cyanosis
  • Tachycardia
  • Restless

3.Imbalanced Nutrition Less Than Body Requirements related to the lack of oral intake
characterized by:
  • Decreased appetite
  • Weight loss: weakness, decreased muscle tone

4. Hyperthermia related to inflammatory processes
characterized by:
  • Increased body temperature


Outcome :

1. Effective airway,
with the following criteria:
  • Adequate ventilation
  • No buildup

2. Optimal gas exchange, adequate oxygenation to the tissue,
with the following criteria:
  • No dyspnoea
  • No cyanosis

3. Clients can meet the needs adequate nutrition,
with the following criteria:
  • Increased appetite
  • Maintain / increase weight

4. No fever
with the following criteria:
  • Body temperature fell within normal limits


Nursing Interventions for Pneumonia

Ineffective Airway Clearance

Independent:

Assess the frequency / depth of breathing and chest movement
R :/ takipneu, shallow breathing, and asymmetrical chest movements often occur because of discomfort or movement of the chest wall and lung fluid.

Help patients breathing exercises frequently. Show / aids patients studied did cough, such as chest presses and effective cough while sitting high
R :/ Breath in facilitating the maximum expansion of the lung / airway smaller. Coughing is a natural cleaning mechanism of airway / help the cilia to maintain a patent airway. Emphasis lower chest discomfort and breathing effort seating position allows deeper and more powerful.

Exploitation as indicated
R :/ Stimulate cough or mechanical airway clearance in patients who are unable to perform because of ineffective cough or a decreased level of consciousness.

Give fluids at least 2500 ml / day (unless contraindicated). Offer warm water rather than cold.
R :/ liquids (especially warm) mobilize and remove secretions.

Collaboration

Assist to monitor the effects of treatment and physiotherapy another nebuliser. For example, an incentive spirometer, blowing bottles, percussion, postural drainage. Take action in between meals and limit fluids when possible.
R :/ Facilitate dilution and removal of secretions. Postural drainage is not effective in causing interstitial pneumonia or alveolar exudate or damage. Coordination of treatment / schedule and oral input vomit degrade because of cough, sputum spending.

Give medications as indicated: mucolytics, expectorants, bronchodilators, analgesic
R :/ equipment for lowering the mobilization of secretions bronchospasm. Analgesics are given to improve the cough by decreasing discomfort but should be used with caution, because it can reduce the effort cough / depress respiration.

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