Nursing Care Plan for Pneumonia
Nursing Diagnosis 1. Ineffective Airway Clearance related to excessive secretions secondary to infection.
Goal : demonstrate a patent airway with breath sounds clean.
Interventions :
1. Assess the frequency / depth of breathing and chest movement.
Rationale : tachypnea , shallow breathing and chest movement is not symmetrical movements often occur due to discomfort or chest wall and the lung fluid.
2. Auscultation of the lung area, note areas of decreased / no air flow and breath sounds crackles.
Rationale : reduction in air flow occurs in the area of consolidation with fluid, crackles audible in response to fluid collection, secret.
3. Provide warm water rather than cold water.
Rationale : warm fluid mobilizing and removing secret.
4. Collaboration of mucolytic , expectorant.
Rationale : helps reduce bronchospasm with secret mobilization.
Nursing Diagnosis 2. Acute Pain related to inflammation of the lung parenchyma.
Goal : pain diminished or disappeared.
Interventions :
1. Determine the characteristics of the pain, ie sharp, stabbed, constant.
Rationale : Chest pain is usually present in some degree in pneumonia, a complication of pneumonia can also occur as pericarditis and endocarditis.
2. Monitor vital signs.
Rationale : changes in heart rate or BP indicates that the patient is experiencing pain.
3. Provide convenient measures, such as : relaxation, massage your back.
Rationale : non- analgesic action is given with a gentle touch can eliminate the discomfort and increase the therapeutic effect of analgesics.
4. Collaboration in analgesic administration.
Rationale : expected to help reduce pain.
Nursing Diagnosis 3. Ineffective Breathing Pattern related to excessive secretion secondary to infection.
Goal : maintain adequate ventilation.
Interventions :
1. Assess the frequency, depth of breathing.
Rationale : tachypnea, shallow breathing often occurs due to discomfort or movement of the chest wall and the lung fluid.
2. Auscultation of breath sounds.
Rationale : indicates the occurrence of complications (additional sound indicates the presence of fluid accumulation / secretion).
3. Monitor vital signs.
Rationale : continuous vital sign abnormalities requiring further evaluation.
4. Collaboration of O2 as indicated.
Rationale : maintain PaO 2 above 60 mmHg.
Nursing Diagnosis 4. Imbalanced Nutrition Less Than Body Requirements related to decreased appetite secondary to nausea and vomiting.
Goal : show increased appetite .
Intrervention :
1. Identification of factors that cause nausea and vomiting.
Rationale : the choice of intervention depends on the causes of the problem.
2. Auscultation of bowel sounds.
Rationale : bowel sounds may be reduced / no if the infection is severe / elongated.
3. Feed small portions but frequently , including food attractive to patients.
Rationale : This action can increase appetite though slow to return.
4. Collaboration of antiemetics.
Rationale : expected to prevent vomiting.
Nursing Diagnosis 5. Activity Intolerance related to imbalance between oxygen supply and demand.
Goal : show increased tolerance to activity.
Interventions :
1. Evaluation of the patient's response to the activity.
Rationale : define needs and facilitate patient choice of intervention.
2. Provide quiet environment and limit visitors during the acute phase as indicated.
Rationale : reduce stress and excessive stimulation , increasing the break.
3. Help needed self-care activities.
Rationale : minimize fatigue and help balance supply and oxygen demand.
Nursing Diagnosis 6. Hyperthermia related to inflammatory lung parenchyma.
Goal : maintain the temperature within normal limits.
Interventions :
1. Monitor the patient's temperature.
Rationale : temperature 38.9 ° C - 41.1 ° C showed an acute infectious disease process.
2 . Give compress warm bath.
Rationale : can help reduce fever.
3. Collaboration of antipyretics.
Rationale : expected to help reduce fever by central action on the hypothalamus.
Nursing Diagnosis 7. Disturbed Sleep Pattern related to frequent waking tehadap secondary respiratory disorders, cough.
Goal : Sleep patterns of patients adequately.
Interventions :
1. Determine usually sleeping habits and changes that occur.
Rationale : the need to assess and identify appropriate interventions.
2. Give a comfortable bed.
Rationale : improve sleep comfort and psychological support.
3. Instruct relaxation action.
Rationale : to help induce sleep.
4. Provide a comfortable position, aids in changing positions.
Rationale : changing the position of the pressure change and improve rest area.
Nursing Diagnosis 8. Risk for Fluid Volume Deficits related to excessive fluid loss from vomiting.
Goal : demonstrate adequate fluid volume.
Interventions :
1. Assess changes in vital signs.
Rationale : the increase in temperature increases the metabolic rate and fluid loss through evaporation.
2. skin turgor , mucous membrane moisture.
Rationale : a direct indicator of the strength of the liquid volume.
3. Make a note of the report of nausea and vomiting.
Rationale : the presence of these symptoms indicate oral input.
4. Collaboration of antipyretics, antiemetics.
Rationale : useful decrease fluid loss.
Nursing Diagnosis 1. Ineffective Airway Clearance related to excessive secretions secondary to infection.
Goal : demonstrate a patent airway with breath sounds clean.
Interventions :
1. Assess the frequency / depth of breathing and chest movement.
Rationale : tachypnea , shallow breathing and chest movement is not symmetrical movements often occur due to discomfort or chest wall and the lung fluid.
2. Auscultation of the lung area, note areas of decreased / no air flow and breath sounds crackles.
Rationale : reduction in air flow occurs in the area of consolidation with fluid, crackles audible in response to fluid collection, secret.
3. Provide warm water rather than cold water.
Rationale : warm fluid mobilizing and removing secret.
4. Collaboration of mucolytic , expectorant.
Rationale : helps reduce bronchospasm with secret mobilization.
Nursing Diagnosis 2. Acute Pain related to inflammation of the lung parenchyma.
Goal : pain diminished or disappeared.
Interventions :
1. Determine the characteristics of the pain, ie sharp, stabbed, constant.
Rationale : Chest pain is usually present in some degree in pneumonia, a complication of pneumonia can also occur as pericarditis and endocarditis.
2. Monitor vital signs.
Rationale : changes in heart rate or BP indicates that the patient is experiencing pain.
3. Provide convenient measures, such as : relaxation, massage your back.
Rationale : non- analgesic action is given with a gentle touch can eliminate the discomfort and increase the therapeutic effect of analgesics.
4. Collaboration in analgesic administration.
Rationale : expected to help reduce pain.
Nursing Diagnosis 3. Ineffective Breathing Pattern related to excessive secretion secondary to infection.
Goal : maintain adequate ventilation.
Interventions :
1. Assess the frequency, depth of breathing.
Rationale : tachypnea, shallow breathing often occurs due to discomfort or movement of the chest wall and the lung fluid.
2. Auscultation of breath sounds.
Rationale : indicates the occurrence of complications (additional sound indicates the presence of fluid accumulation / secretion).
3. Monitor vital signs.
Rationale : continuous vital sign abnormalities requiring further evaluation.
4. Collaboration of O2 as indicated.
Rationale : maintain PaO 2 above 60 mmHg.
Nursing Diagnosis 4. Imbalanced Nutrition Less Than Body Requirements related to decreased appetite secondary to nausea and vomiting.
Goal : show increased appetite .
Intrervention :
1. Identification of factors that cause nausea and vomiting.
Rationale : the choice of intervention depends on the causes of the problem.
2. Auscultation of bowel sounds.
Rationale : bowel sounds may be reduced / no if the infection is severe / elongated.
3. Feed small portions but frequently , including food attractive to patients.
Rationale : This action can increase appetite though slow to return.
4. Collaboration of antiemetics.
Rationale : expected to prevent vomiting.
Nursing Diagnosis 5. Activity Intolerance related to imbalance between oxygen supply and demand.
Goal : show increased tolerance to activity.
Interventions :
1. Evaluation of the patient's response to the activity.
Rationale : define needs and facilitate patient choice of intervention.
2. Provide quiet environment and limit visitors during the acute phase as indicated.
Rationale : reduce stress and excessive stimulation , increasing the break.
3. Help needed self-care activities.
Rationale : minimize fatigue and help balance supply and oxygen demand.
Nursing Diagnosis 6. Hyperthermia related to inflammatory lung parenchyma.
Goal : maintain the temperature within normal limits.
Interventions :
1. Monitor the patient's temperature.
Rationale : temperature 38.9 ° C - 41.1 ° C showed an acute infectious disease process.
2 . Give compress warm bath.
Rationale : can help reduce fever.
3. Collaboration of antipyretics.
Rationale : expected to help reduce fever by central action on the hypothalamus.
Nursing Diagnosis 7. Disturbed Sleep Pattern related to frequent waking tehadap secondary respiratory disorders, cough.
Goal : Sleep patterns of patients adequately.
Interventions :
1. Determine usually sleeping habits and changes that occur.
Rationale : the need to assess and identify appropriate interventions.
2. Give a comfortable bed.
Rationale : improve sleep comfort and psychological support.
3. Instruct relaxation action.
Rationale : to help induce sleep.
4. Provide a comfortable position, aids in changing positions.
Rationale : changing the position of the pressure change and improve rest area.
Nursing Diagnosis 8. Risk for Fluid Volume Deficits related to excessive fluid loss from vomiting.
Goal : demonstrate adequate fluid volume.
Interventions :
1. Assess changes in vital signs.
Rationale : the increase in temperature increases the metabolic rate and fluid loss through evaporation.
2. skin turgor , mucous membrane moisture.
Rationale : a direct indicator of the strength of the liquid volume.
3. Make a note of the report of nausea and vomiting.
Rationale : the presence of these symptoms indicate oral input.
4. Collaboration of antipyretics, antiemetics.
Rationale : useful decrease fluid loss.
