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Thursday, April 22, 2010

Nursing Care Plan for Pneumonia

pneumonia

Nursing Plan

Breath Pattern ineffectiveness because of pulmonary infection


Characteristics :

Cough (both productive and non productive), shortness of breath, Tachipnea, breath sounds are limited, retraction, fever, diaporesis, ronchii, cyanosis, leukocytosis.


Goal :

Effective breathing pattern characterized by :
  • Voice of lung breath clean and the same on both sides
  • The temperature of the body within the limits of 36.5 to 37.2 OC
  • The rate of breathing in the normal range
  • There is no coughing, cyanosis, retraction and diaporesis

Intervention :
  • Perform assessments every 4 hours of respiratory rate, temperature, and signs of airway effectiveness.
    Rational: Evaluation and reassessment of the actions that will be / have been granted.

  • Perform scheduled Phisioterapi chest
    Rational: Removing the secretion of the airway, preventing obstruction

  • Give Oxygen
    Rational: Increased lung tissue oxygen supply

  • Give antibiotics and antipyretics, assess the effectiveness and side effects (rash, diarrhea)
    Rational: Eradication of the bacteria as a factor of disturbance causa

  • Make checks thoracic photo
    Rational: The evaluation of the effectiveness of the circulation of oxygen, evaluated the condition of lung tissue

  • Perform a gradual suction
    Rational: Helping airway clearance

  • Record the results of the pulse oximeter when installed, every 2 - 4 hours
    Rational: Periodically Evaluate the success of therapy / health team action.

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