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Thursday, May 10, 2012

Nursing Management for Pneumonia

Nursing Management for Pneumonia

Assessment for Pneumonia

1. Activity / rest
  • Symptoms: weakness, fatigue, insomnia
  • Signs: lethargy, decreased activity tolerance.
  • Signs: tachycardia, the appearance of redness, or pale.
3. Food / fluid
  • Symptoms: loss of appetite, nausea, vomiting, history of diabetes mellitus
  • Symptoms: Abdominal consistency, dry skin with poor turgor, cachexia appearance
  • (malnutrition).
4. Neuro-sensory
  • Symptoms: headache frontal area (influenza)
  • Symptoms: mental destruction (confused)
5. Pain / comfort
  • Symptoms: headache, chest pain (increased by coughing), imralgia, arthralgia.
  • Signs: protecting the sore area (sleeping on the affected side to restrict the movement)
6. Breathing
  • Symptoms: a history of chronic UTI, tachypnoea (shortness of breath), dyspnea.
  • o Sputum: pink, rusty
  • o perfusion: a flat area of consolidation of deaf
  • o premikus: taksil and vocals gradually increased with the consolidation
  • o decreased breath sounds
  • o Color: pale / cyanotic lips and nails
7. Security
  • Symptoms: a history of immune system disorders such as: AIDS, steroid use, fever.
  • Signs: sweating, chills over and over, shaking
8. Education / learning
  • Symptoms: a history of surgery, chronic alcohol use
  • Mark: indicates the average length DRG treated 6-8 days
  • Repatriation plan: assistance with personal care, home maintenance tasks.

Nursing Management for PneumoniaNursing Management for Pneumonia

A. Effective airway, pulmonary ventilation is adequate and there is no secret buildup.

Plan of action:
1) Monitor respiratory status every 2 hours, examine an increase in respiratory status and abnormal breath sounds.
2) Perform percussion, vibration and postural drainage every 4-6 hours.
3) Give appropriate oxygen therapy program.
4) Help cough up secretions / suction lenders.
5) Give the comfortable position that allows the patient to breathe.
6) Create a comfortable environment so that patients can sleep in peace.
7) Monitor blood gas analysis to assess respiratory status.
8) Give drink.
9) Provide sputum for culture / sensitivity test.

B. Patients showed improvement of ventilation, gas exchange and the optimal oxygenation of tissues adequately.

Action Plan:
1) Observe level of consciousness, respiratory status, signs of cyanosis every 2 hours.
2) Give Fowler's position / semi-Fowler.
3) Give oxygen according to the program.
4) Monitor blood gas analysis.
5) Create a quiet environment and patient comfort.
6) Prevent the occurrence of fatigue in patients.

3. Patient will maintain normal body fluids.

Action Plan:
1) Record fluid intake and output. Encourage mothers to give fluids orally tetaap à avoid milk is thick / cold drinking à stimulate coughing.
2) Monitor fluid balance à mucous membranes, skin turgor, rapid pulse, decreased consciousness, vital signs tyanda.
3) Maintain the accuracy of the droplet infusion according to the program.
4) Perform oral hygiene.

4. Patients can perform activities according to the conditions.

Action Plan:
1) Assess the patient's physical tolerance.
2) Assist patients in activities of daily activities.
3) Provide age-appropriate games with the activity of patients who did not spend much energy à adjust activities to the condition.
4) Give the O2 according to the program.
5) Give the energy needs.

Nursing Interventions for Pneumonia

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