Nursing Management for Pneumonia

Nursing Management for Pneumonia

Assessment for Pneumonia

1. Activity / rest

• Symptoms: weakness, fatigue, insomnia
• Signs: lethargy, decreased activity tolerance.

2.Circulation

• 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.

mark:

• 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 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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Nursing Interventions for Pneumonia

Pneumonia, acute infection of the lung parenchyma, interstitial lung tissue in which fluid and blood cells escape into the alveoli. that often impairs gas exchange. Pneumonia classified in several ways.

Based on microbiological etiology origin:

• Viral
• Bacterial
• Fungal
• Protozoa
• Mycobacterium
• Mycoplasmal
• Rickettsial

Based in location, pneumonia can be classified:

Bronchopneumonia, Bronchopneumonia involves distal airways and alveoli
Lobular pneumonia or lobar pneumonia. In this pneumonia involves part of a lobe; and lobar pneumonia, an entire lobe

The infection is also classified as one of three types:

Primary pneumonia

Primary pneumonia results directly from inhalation or aspiration of a pathogen, such as bacteria or a virus; it includes pneumococcal and viral pneumonia.

Secondary pneumonia

Secondary pneumonia may follow initial lung damage from a noxious chemical or other insult (superinfection) or may result from hematogenous spread of bacteria from a distant area.

Aspiration pneumonia

Aspiration pneumonia results from inhalation of foreign matter, such as stomach contents vomitus or food particles, into the bronchi. It’s more likely to occur in elderly or debilitated patients, those receiving nasogastric tube feedings, higher prevalence those with an impaired gag reflex, poor oral hygiene, or a decreased level of consciousness.

Nursing Interventions for Pneumonia

Intervention and Rationale:
I. Assess for:

• Respiratory status including rate, depth, ease, shallow or irregular breathing, dyspnea, use of accesory muscles, and diminished breath sounds, rhonchi or crackles on auscultation - provides data baseline.
• Changes in mental status, skin color, cyanosis - indicates possible decrease in oxygenation.
• Quality of cough and ability to raise secretions including consistency and characteristics od sputum - removal of secretions prevents obstruction of airways and stasis leading to further infection and consolidation of lungs; clearing airways facilitates breathing.

II. Monitor, record, describe:
Respiratory rate, quality and breath sounds q2-q4 - indicates airway resistance, air movement, severity of disease.

• ABGs, oximeter reading - decreased oxygen levels result in hypoxemia.

III. Administer:

• Oxygen therapy via cannula - maintain optimal oxygen level.
• Antitussives/expectorants (terpin hydrate, guaifenesin) - acts on bronchial cells to increase fluid production and promote expectoration; guaifenesin reduces surface tension of secretions; both relieve non-productive cough
• Mucolytic (acetylcysteine) - decrease viscosity of mucus for easier removal.
• Antibiotic (ampicillin, cephalexin) - acts by binding to cell wall organisms preventing synthesis and destroying pathogens.

IV. Perform or Provide:

• Position of comfort in semi or high fowlers and change position q2h - facilitates breathng and allows for full expansion of lungs.
• Encourage coughing if sounds is moist; if dry and hacking, increase fluid intake and administer cough suppresant - reduces continual irritation to throat and liquefies secretions.
• Coughing and deep breathing exercise q2h; use incintive spirometer 5-10 breaths if tolerated - coughing clears airway by propelling secretions to mouth deep breathing promoes ventilation and prolongs expiratory phase.
• Assist with coughing by splinting chest; humidified air with cool mist - loosens seretions and improves ventilation, moistens mucous membranes
• Postural drainage and percussion PRN - mobilizes secretion.
• Suction secretions if cough ineffective - removal if unable to bring up secretions.
• Oral care after expectoration and provide tissues and bag for disposal - promotes comfort and prevents transmission of organisms to others.

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