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.
