XII.

NURSING CARE PLAN NURSING DIAGNOSI S Ineffective airway clearance related to excessive mucus secretions as manifested by dyspnea, adventitiou s breath sounds, changes in the respiratory rate, restlessnes s and ineffective cough ANALYSIS Pneumonia is an inflammatory condition of the lung. It is often characterized as including inflammation of the parenchyma of the lung, the alveoli and abnormal alveolar filling with fluid consolidation and exudation. Pneumonia is a serious infection that affects the air sacs in the lungs, resulting to significant GOALS and OBJECTIVES Goal: After 40 minutes of nursing intervention, the client would be able to have patent airway by expectorating retained secretions. Objectives: Independen t 1. After 5 minutes intervention, the client would be able to have normal breath respiration and breath Independent 1.1Monitor respiration and breath sounds Tachypnea, stridor, crackles or wheezes are indicative to repiratory distress and/or accumulation of fluid (Nurse's Pocket Guide by Doenges Breath sounds form crackles to bronchovesic u-lar sounds NURSING INTERVENTIO N RATIONALE EVALUATIO N

CUES Subjective: The mother quoted "hirap makahinga yung anak ko tapos parang irritable siya palagi" The mother also stated, Nakabukas din ang bibig ng baby ko kapag humihinga. She verbalized that he often cries maybe because he has difficulty of breathing due to his

1.2 Monitor infant/child for

Rizal Medical Center/Payward-A CJPV Case Study | BSN 202 Group 8B

cough and colds. Cough for 4 days Objective: RR= 55 cpm PR= 140 bpm Restless Nasal discharge (+) coarse crackles (+) wheezes (+) DOB (+) shallow retractions Lab: CXR-hazy and reticulonodul ar opacities in both inner lung zones

reduction in oxygenation. Because of this, the oxygen will have difficulty reaching the blood. If there is too little oxygen in the blood, body cells cannot work properly. As a result, infection will spread.

sounds within feeding 20 minutes. intolerance, abdominal distention and emotional stressor 2.1 Place the client in high fowler's position

2. After 5 minutes of nursing intervention, the client The alveoli would be are able to have microscopic easier 3.1Perform air filled sacs breathing Chest in the lungs within 5 Physiotherapy responsible minutes for gas exchange. Pneumonia 3. After 10 can result minutes of from a variety nursing of causes, intervention, including the client infection with would be bacteria, able to viruses, fungi, mobilize

et al pp.78) These factors may compromise airway (Nurse's Pocket Guide by Doenges et al pp.79) The client was able to have easier breathing Positioning the client in high fowler's position promote lung expansion (Fundamental s of Nursing The client by Kozier was able to pp.789) mobilize secretions Chest Physiotherapy is used to mechanically dislodge tenacious secretions from the bronchial

Rizal Medical Center/Payward-A CJPV Case Study | BSN 202 Group 8B

or parasites, secretions and chemical within 15 3.2 Suctioning or physical minutes injury to the lungs. Its cause may also be officially described as unknown when infectious causes have been excluded. 3.3 Increased Typical fluid intake symptoms associated with pneumonia include cough, chest pain, fever, and difficulty in breathing. Dependent: Diagnostic 4.1 Administer tools include bronchodilator x-rays and s as ordered examination by the of the physician sputum. Treatment

walls (Nursing CareManage ment Skill Manual pp.60) Suction is used to clear airway when excessive or viscous secretions are blocking the airway or client is unable to cough effectively (Nurse's Pocket Guide by Doenges et al pp.78) Hydration can help liquefy viscous secretions and improve secretion clearance (Nurse's Pocket Guide

The client was able to take the medications and treatment prescribed by

Rizal Medical Center/Payward-A CJPV Case Study | BSN 202 Group 8B

depends on the cause of pneumonia; bacterial pneumonia is treated with antibiotics

Pneumonia is common occurring in all age groups, and is a leading cause of death among the young, the old, and the chronically ill. Vaccines to prevent certain types of pneumonia are available. The prognosis depends on the type of pneumonia, the treatment, any Interdepend complications, ent and the 5.After 10

Dependent: 4. After 10 minutes of nursing intervention, the client would be able to take the medications and treatment prescribed by the physician within the order time and date of administratio n

Doenges.79)

4.2 Perform oxygen therapy or administer oxygen by nasal cannula

the physician within the order time Bronchodilato and date of rs are anti- administratio inflammtory n. drugs, expectorants and cough suppressants that may treat respiratory problems. (Fundamental s of Nursing by Kozier pp.1369)

Administration of oxygen to 5.1 Instruct client to relatives to prevent or perform proper relieve nebulization hypoxia. (Nursing CareManage ment Skill Manual pp.55) Nebulization is performed to deliver

The relatives were able to perform proper humidificatio n and administer medication via nebulization.

Rizal Medical Center/Payward-A CJPV Case Study | BSN 202 Group 8B

person's underlying health. The seriousness of pneumonia depends on the type of pneumonia and overall health status of the person. The very young and the very old are high risk groups for development of serious complications from pneumonia

minutes of nursing intervention, the client's relatives would be able to perform proper humidificatio n and administer medication via nebulization

finer mist at a faster rate to moisten membrane. (Nursing CareManage ment Skill Manual pp.69)

Rizal Medical Center/Payward-A CJPV Case Study | BSN 202 Group 8B