NURSING CARE PLAN

ASSESSMENT
Subjective: Masakit ang dibdib ko as verbalized by patient. Objective: Use of accessory muscle. Dyspnea Fatigue. V/S taken as follows: T: 37.3 P: 80 R: 25 Bp: 120/80

DIAGNOSIS
Acute pain r/t localized inflammation and persistent cough.

INFERENCE Pneumonia is inflammation of the terminal airways and alveoli caused by acute infection by various agents. Pneumonia can be divided into three groups: community acquired, hospital or nursing home acquired (nosocomial), and pneumonia in an immunocompr omised person. Causes include bacteria (Streptococcu s, Staphylococcu s,

PLANNING
After 4 hours of nursing interventions , the patient will display patent airway with breath sounds clearing and absence of dyspnea.

INTERVENTION
Independent: Elevate head of the bed, change position frequently.

RATIONALE
Lowers diaphragm, promoting chest expansion and expectoration of secretions. Deep breathing facilitates maximum expansion of the lungs and smaller airways. Coughing is a natural self cleaning mechanism. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort. Fluids especially warm liquids aid in mobilization and expectoration of secretions.

EVALUATION
After 4 hours of nursing intervention s, the patient was able to display patent airway with breath sounds clearing and absence of dyspnea.

Assist patient with deep breathing exercises.

Demonstrate or help patient learn to perform activity like splinting chest and effective coughing while in upright position.

Force fluids to at least 3000 ml per day and offer warm, rather than cold fluids.

Haemophilus influenzae, Klebsiella, Legionella). Community Acquired Pneumonia (CAD) is a disease in which individuals who have not recently been hospitalized develop an infection of the lungs. It is an acute inflammatory condition thats result from aspiration of oropharyngeal secretions or stomach contents in the lungs.

Collaborative: Administer medications as prescribe: mucolytics or expectorants. Provide supplemental fluids.

Aids in reduction of bronchospas m and mobilization of secretions. Fluids are required to replace losses and aid in mobilization of secretions.