Plan and Nursing Pneumionia

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Plan and Nursing Pneumionia

Plan and Nursing Pneumionia

Definition

Pneumonia is an inflammation of the lung disease characterized by the consolidation due to exudates that enter the area of ​​the alveoli. (Axton & Fugate, 1993)

Cause
- Influenza Virus

- Respiratory Virus Synsitical

- Adenovirus

- Rhinovirus

- Rubeola

- Varisella

- Micoplasma (in children is relatively large)

- Pneumococcus

- Streptococcus

- Staphilococcus


Signs and Symptoms
v Shortness of Breath

v nonproductive cough

v Snot (nasal discharge)

v Sounds weak breath

v intercostal retraction

v Use of auxiliary respiratory muscles

v Fever

v Ronchii

v CNS

v leukocytosis

v Thorax photo shows infiltration widens


Type

Lobular pneumonia

Bronchopneumonia

Assessment

Identity:

Age: Children are prone to virus infection than adults

Mycoplasma occurs in children is a relatively large

Residence: Environments with poor sanitation at greater risk

Login History

Children are usually taken to hospital after shortness of breath, cyanosis or coughing accompanied with high fever. Consciousness is sometimes already declining when the child goes along with a history of febrile seizure (seizure).

History Formerly Disease

Predilection other respiratory diseases such as respiratory infections, influenza often occurs within the period of 3-14 days before known of the disease pneumonia.

Lung disease, heart and vital organs congenital abnormalities may aggravate the clinical patient

Assessment

1. Integumentary System

Subjective: -

Objective: pale skin, cyanosis, decreased turgor (due to dehydration secondary), a lot of perspiration, skin temperature increases, redness

2. Pulmonary System

Subjective: shortness of breath, chest pressure, crybaby

Objective: Respiratory nostril, hyperventilation, cough (productive / nonproductive), sputum many, the use of auxiliary respiratory muscles, diaphragm and abdominal breathing increases, breathing rate increases, audible stridor, ronchii the lung field,

3. Cardiovascular system

Subjective: headache

Objective: increased pulse rate, blood vessel vasoconstriction, decreased blood quality

4. Neurosensori System

Subjective: restlessness, decreased consciousness, seizures

Objective: GCS decreased, reflexes decreased / normal, lethargy

5. Musculoskeletal System

Subjective: weak, tired

Objective: decreased muscle tone, muscle pain / normal, lung retraction and use of accessory respiratory muscles

6. Genitourinary system

Subjective: -

Objective: urine production decreased / normal,

7. Digestive system

Subjective: nausea, sometimes vomiting

Objective: the consistency of normal stool / diarrhea

Laboratory studies:

Hb: decreased / normal

Blood Gas Analysis: Respiratory acidosis, decreased blood oxygen levels, carbon content of blood increases to normal

Electrolytes: Sodium / calcium decreased / normal

Nursing Plan

1. Ineffective breathing pattern b.d Lung Infection

Characteristics: cough (both productive and non productive) nasal output, shortness of breath, Tachipnea, breath sounds are limited, retraction, fever, diaporesis, ronchii, cyanosis, leukocytosis

Objectives:

Children will experience effective breathing pattern characterized by:

Lung breath sounds clean and the same on both sides

Body temperature within the limits from 36.5 to 37.2 OC

The rate of breathing in the normal range

There was no cough, cyanosisi, output nose, retraction and diaporesis

Nursing action

Perform assessments every 4 hours to RR, S, and the signs of the effectiveness of airway

R: Evaluation and reassessment of the actions that will be / have been given

Perform scheduled Phisioterapi chest

R: Remove the secretion of the airway, preventing obstruction

Give Oxygen moist, review the effectiveness of therapy

R: Increased lung tissue oxygen supply

Give appropriate antibiotics and antipyretic orders, review the effectiveness and side effects (rash, diarrhea)

R: Eradication of bacteria as a factor of disturbance causa

Make a check count of human resources and photo thoracic

R: Evaluation of the effectiveness of the circulation of oxygen, evaluating the condition of lung tissue

Perform suction gradually

R: Helping cleaning airway

Record the results of pulse oximeter when installed, every 2-4 hours

R: Evaluate periodically the success of therapy / health team action

2. Fluid Volume Deficit b.d:

- Respiratory Distress

- Decrease in fluid intake

- Improved IWL rapid breathing and fever due to

Characteristics:

Loss of appetite / drinking, lethargy, fever., Vomiting, diarrhea, dry mucous membranes, poor skin turgor, decreased urine output.

Objective: Children receive adequate amount of fluid is characterized by:

Adequate Intake, either IV or oral

The absence of lethargy, vomiting, diarrhea

Body temperature within normal limits

Urine output is adequate, BJ Urine 1008 to 1.020

Nursing Intervention:

Record intake and output, heavy diapers for output

R: Evaluation strict intake and output needs

Assess and record the temperature every 4 hours, signs devisit line IV fluids and conditions

R: Convincing fluid needs are met

Note BJ Urine every 4 hours or if necessary

R: Evaluation of a simple objective devisit fluid volume

Perform oral care every 4 hours

R: Increasing the clearance sal indigestion, increased appetite / drinking

Other Diagnosis:

1. Changes in Nutrition: Less than bd needs anorexia, vomiting, increased caloric intake secondary to infection

2. Changes in the comfort bd headache, chest pain

3. Bd activity intolerance respiratory distress, latergi, decreased intake, fever

4. Anxiety b.d hospitalization, respiratory distress

Reference:

Acton, Sharon Enis & Fugate, Terry (1993) Pediatric Care Plans, AddisonWesley Co. Philadelphia

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