Nursing PNEUMONIA

Nursing PNEUMONIA

care%2Bplan Nursing PNEUMONIA

INTRODUCTION
Peneumonia is an inflammation of the lungs usually caused by bacterial infection (staphylococcus, pneumococcus, or streptococcus) or viruses (respiratory syncytial virus). The cause of the less frequent are Mycoplasma, foreign body aspiration, and mushrooms. Seabagai incidence of primary disease or complications of other diseases, pneumonia is characterized doleh a thick exudate that clog the alveoli and decrease oxygen exchange. Bacteria or viruses from pneumonia can begin quickly.
It usually occurs in infants and young children more easily, pneumonia can occur at any age, with incidence teertinggi during late fall, winter and early spring. Treatment mainly respiratory support in the form of viruses and antibiotics and respiratory support in the form of bacteria.
ASSESSMENT
Respiration

Increased respiratory rate
Retraction
Chest pain
Crackles
Decrease in breath sounds
Nasal flaring
Cyanosis
Productive cough
Ronchi.

Cardiovascular

Tachycardia

Neurological

Headache
Irritability
Difficulty sleeping

Gastrointestinal

Decrease appetite
Stomach pain

Musculoskeletal

Nervous
Fatigue

Integumentary

Peningatan body temperature
Cyanosis around the lips.

Nursing Diagnosis
Pertukran disorders associated with accumulation of gas and increased production of mucus exudate.

Expected results
Children will increase the exchange of gases is characterized by simple breathing, normal skin color, decreased anxiety.

Intervention

Adjust the position of which can increase the comfort children
create a humid and cold environment with the use of face shield, hood oxygen, or oxygen tent.
Give oxygen using a face shield, hood oxygen, or iksigen tent, according to the instructions.
Encourage the child to cough and deep breathing exercises every 2 hours
Perform suctioning mucus, if necessary. Prepare suction equipment mucus near the child.
Perform chest physiotherapy every 4 hours, or as directed.
Assess the respiratory status of children to mark the presence of dyspnea, Tachypnoea, wheezing, crackles, ronchi, and cyanosis.
Give a break as often as possible.
Robah child’s position every 1 to 2 hours.

Rational

provide a comfortable position, such as semi-erect position, make a child breathe easily.
Dilembab cold air in the airway, help thin mucus and reduce bronchial iedema.
Oxygen helps to reduce anxiety associated with respiratory disorders and hypoxemia.
Coughing helps remove mucus; breath in encouraging the expansion of the lung.
Mucus suctioning is recommended to keep the airway free, especially if the child is not an effective cough.
Chest physiotherapy to help eliminate the exudate and mucus out easily by coughing and suctioning of mucus.
These signs may indicate that the treatment is ineffective and that the child’s condition became worse.
Liquids are generally thin mucus
Rest save energy needed to fight infection
Change the position of lying on a regular basis helps to mobilize mucus expenditure.

Nursing Diagnosis
Hyperthermia associated with infection

Expected results
Children will maintain body temperature less than 100 ˚ F (37.8 ˚ C)

Intervention

Maintain a cool environment
Give antipyretics (acetamoniphen or ibuprofen, not aspirants), as directed.
Monitor the child’s temperature every 1 to 2 hours the possibility of a sudden rise.
Take the preparation of sputum for culture
Give antimicrobials, according to the instructions.
Give a wet compress (98.6 ˚ F [37 ˚ C]), if necessary, to reduce fever.

Rational

Cool environment will help reduce the temperature through heat loss by radiation.
Antipyretics reduce fever usually effectively in order to return to the normal starting point.
Increased body temperature suddenly can menbgakibatkan seizures.
Sputum preparation help mengidenfifikasi causative agent
Antimicrobials will attack the organisms causing
Konpres cold wet on the surface of the body eliminates body temperature by conduction.

Nursing Diagnosis
Risk reduction in fluid volume associated with fluid loss due to hyperthermia or hiperpnea (or both).

Expected results
Children will mempertanhankan fluid balance is characterized by a urine output of 1 to 2 ml / kg / h, good skin turgor and capillary refill time of 3 to 5 seconds.

Intervention

carefully monitor intake and output fluid
Kaji increase the child’s breathing and fever freluensi every 1 to 2 hours
Assess for signs of dehydration in children, including oliguria, poor skin turgor, dry kukosa membranes, and hollow in the crown and eyeballs.
Give perinfus fluid, according to instructions.
Encourage oral fluid intake per every 1 to 2 hours, if not contraindicated.

Rational

carefully monitor will detect a decrease in urine output, which can indicate dehydration.
Increased frequency of breathing and body temperature results in increased loss of fluid.
These signs indicate an increased need for fluid intake.
Diperlukanm intravenous fluids per child in order to maintain adequate hydration.
Increasing fluid intake helps prevent dehydration and mengenceran mucus.

Nursing Diagnosis
Ineffective airway clearance is associated with inflammation.
Expected results
Children will be reduced perioden difficulty breathing is characterized by adequate rest and breathing within normal limits according to age.

Intervention
1. Lung Auscultation signs of increased swelling and possible airway obstruction, including dyspnea, Tachypnoea, and wheezing, and review salivation.
2. avoid direct stimulation of the airway with an emphasis on the tongue, culture swabs, suction catheter, or laryngoscope.
3. Let the kids on a fun variety of positions except the horizontal position.
4. Monitor respiratory status and vital signs continuously until the road is guaranteed free air. Let the emergency intubation equipment at the bedside.
Rational

Know the early signs are very necessary because the swelling usually goes quickly and can be fatal.
handling actions on the network in the airway can cause laryngeal spasm and swelling, the possibility of raising the perfect obstruction.
Horizontal position can cause rapid deterioration of the network, is likely to increase the obstruction perfect.
Monitoring continuously set because increasing edema may cause obstruction perfect at any one time, and requires action by emergency intubation.

Nursing Diagnosis
Nutritional deficiencies: lack of demand associated with increased metabolic demand.

Expected results
Children will increase the intake of nutrients is characterized by eating more than 80% of food until the end tinggakl hospitalized.

Intervention

Defend your child’s diet high in protein, high calorie.
Give a little food, often food sisukai.
Avoid milk and full-strength formula

Rational

Children need a diet high in peotein and calories to gain increased energy needs.
eat a little, and often will pengurangi expiratory effort. Providing food for children who liked to help more food at every meal.
Milk and formula will thicken mucus.

Nursing Diagnosis
Anxiety (parents) relating to the lack of knowledge about the condition of the child.

Expected results
Parents will be reduced his anxiety is characterized by its ability to provide kudungan in children and explain the child’s condition.

Intervention

Assess understanding of parents will the child’s condition and treatment provided.
Make sure parents stay with children during their stay in hospital care.
Explain all procedures in children and the elderly.
provide emotional support to parents during the child-patient stay in hospital.

Rational

The assessment provides a basis to begin teaching.
allow parents to stay orangh will provide support to her child.
Provide an explanation before treatment and during their stay in hospital care will increase the knowledge and avoid mistakes serbagai understanding, will reduce anxiety.
hear the feelings of parents and attention helps him to handle the crisis hospitalization.

Nursing Diagnosis
Lack of knowledge related to home care.

Expected results
The parents will express pemahamannnya about home care instructions.

Intervention

Advise parents how and when to provide treatment; provide an explanation in a biodegradable dosage and possible reaction.
Explain the signs and symptoms of respiratory disorders and infection, including fever, dyspnea, Tachypnoea, berwarnah sputum is yellowish or greenish, and the presence of wheezing.
Explain the need for adequate rest in children.
Suggest that parents provide humidity environment by providing moisturizing cold.
Do it gradually gun to prevent respiratory infections that may occur.

Rational

Understanding the importance of regular treatment can help parents follow the treatment program. Knowing the possibility of further reaction, parents will immediately contact a doctor if necessary.
know the signs and symptoms will be able to encourage parents quickly contact a doctor if necessary.
Liquids help thin the mucus; high-calorie diet helps keep the calories needed against the disease.
Humidified air which helps thin the mucus. Cold air is used dibading with warm air as it can cause burns.
Recurrent respiratory infections memingkatan endless problems.

Documentation checklist
During his stay in hospital care, notes:
The situation of children and pengkajianyang performed during hospitalization.
Changes in the situation of children
Dealing with the results of laboratory and test diaghnostik
Fluid intake and output
Nutrition
Response of children to treatment
The reaction of children and parents of sick and stayed in hospital care.
Guidelines for teaching patients and their families
Guidelines for follow-up plan.