PNEUMONIA

Pneumonia is an inflammation of the lung parenchyma, usually associated

with the filling of the alveoli with fluid. Likely causes include various infectious
agent, chemical irritants, and radiation therapy . The care plan deals with bacterial
and viral pneumonia e.g. pneumococcal pneumonia, pneumocysnscarinni,
haemophilus influenza, mycoplasma, gram negative.
Especial Sigh
Especial Sigh which often become the reason of client of pneumonia to
ask help of health is out of breath, cough and improvement of body temperature /
fever

History of Health Now

This study is shellac to support especial sigh. Conduct the question having
the character of summary and answer is only given by a client yes or not or only
the nod lead.

If especial sigh is coughing hence the important nurse to ask have how
long the sigh cough to emerge ( onset). Initially the sigh cough unproductive but
hereinafter will round into to cough productive by mucus [is] purulence,
yellowish, green ship, chocolate or squeezing and oftentimes stink.

Generally client got by sigh of high fever and tremble ( awitan maybe
sudden and dangerous). existence of Sigh of pain in bone of chest pleuritic, out of
breath and improvement of exhalation frequency, feel weakness, pain in bone
lead.

At the study of other treatment at client of pneumonia of a more regular

met at :
1.The children of pneumonia of a more regular from adult
2.Client generally reside in environment by sanitation is ugly
3.Client suffering from weakening ( AIDS, cancer), client with existence of
history breath in or aspiration can be looking vitamin irritant
4.Client by Imobilisasi is old physical with degradation of ability to cough
effective
5.Client with existence of gift of food [of] through pipe continuously
6.Client accepting immunosuppressive of drugs( chemotherapy,
corticosteroid), client getting therapy of anti wide microbial spectrum
7.Client with degradation mount awareness ( stupor, lethargy, pra-koma,
comma).

History of Former Health

Study in aiming at some times previously whether/what experiencing of
infection of channel of exhalation for ( red lane hurt, kingesti nasal, sneezing,
light fever)

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 Study of Psychosocial And Spiritual
Psychological Study of client cover some dimension enabling nurse to
obtain; get clear perception hit status emotion, cognate, and behavior of client.
Nurse collect early inspection of client about physical capacities and intellectual
in this time, determining storey level the importance of study psychosocial
spiritual which careful. Pneumonia client clinic condition often experience of
dread as according to natural sigh of.
Asking settlement condition where client reside, pneumonia client often met
when residing environment by ugly sanitation

Pneumonia is an inflammation of the lung parenchyma, usually associated

with the filling of the alveoli with fluid. Likely causes include various infectious
agent, chemical irritants, and radiation therapy . The care plan deals with bacterial
and viral pneumonia e.g. pneumococcal pneumonia, pneumocysnscarinni,
haemophilus influenza, mycoplasma, gram negative.

A. ASSESSMENT
1. Activity / rest
May report : Fatigue, weakness, insomnia
May exhibit : Lethargy, decreased tolerance to activity

2. Circulation
May report : History of recent / chronic CHF
May exhibit :Tachycardia, cyanosis, flushed appearance of pallor.

3. Ego integrity
May report : Multiple stressors, financial concern

4. Food / fluid
May report : Loss of appetite, nausea vomiting, history of diabetes
mellitus
Ma exhibit : Distended abdomen, hyperactive bowel sound, dry skin
with poor turgor, cachectic appearance (malnutrition)

5. Neurosensory
May report : frontal headache ( influenza)
May exhibit : changes in mentation ( confusion, somnolence)

6. Pain / comfort
May report : Headache, chest pain (pleuritic), aggravated by cough,
subternal chest pain (influenza), myalgia, arthragia.
May exhibit : Splinting / guarding over affected area ( patient commonly
lies on effected side to restrict movement.

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 7. Respiration
May report : History of recurrent / chronic URI, COPP, cigarette
smoking, tachypnea, progressive dyspnea, shallow
grunting respirations, use of accessory muscle, nasal
plaring.
May exhibit : Sputum, rusty, or purulent.
Percussion : pull over consolidated area
Fremitus : tactile and vocal gradually increases with
consolidation pleural friction rub.
Breath sound : diminished or absent over involved area,
or bronchial breath sounds over area of
consolidation. Coarse inspiratory crackles,
Color : pallor or cyanosis of lips / nail beds.

8. Safety
May report : Fever (e.g..38,5 – 39,6 C0)
May exhibit : Diaphoresis, shaking / recurrent chills , rash may be noted
in cases of rubeola or varicella.

B. NURSING DIAGNOSIS

1 Airway clearance, ineffective may be related to decreased energy, fatigue and

tracheal bronchial inflammation, edema formation, increased sputum
production.
Evaluation criteria : Identify / display behaviors to achieve airway clearance.
Interventions Rationale
a. Assess rate / depth of respirations a. Tachypnea, shallow respirations
and chest movement and asymmetric chest movement
are frequently present because of
discomfort of moving chest wall
and / or fluid in lung
b. Auscultation lung fields b. Decreased airflow occurs in areas
consolidated with fluid. Bronchial
breath sound (normal over
bronchus) can also occur in
consolidated areas.
c. Assist patient with frequent deep c. Deep breathing facilitates
– breathing exercise. maximum expansion, of the
lungs / smaller airway.
d. Force fluids to at least 2500 ml/d d. Fluids (especially warm liquids)
(unless contra indicated). Offer aid in mobilization and
warm, rather than cold, fluids. expectoration of secretions.

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2 Gas exchange, impaired may be related to alveolar – capillary membrane
changes (inflammatory effects).
Evaluation criteria : demonstrate improved ventilation and oxygenation of
tissues by ABGs within patients normal range and absence of symptoms of
respiratory distress.

Interventions rationale
a. Assess respiratory rate, depth, and a. Manifestation of respiratory
ease. distress are dependent on / and
indicative of the desire of lung
involvement and underlying
general health status.
b. Assess mental status. b. Restlessness, irritation, confusion,
and somnolence may reflect
hypoxemia / decreased cerebral
oxygenation.
c. Monitor heart rate / rhythm. c. Tachycardia usually present as a
result of fever / dehydration but
may represent a response to
hypoxemia.

3 Infection, high risk for (spread) may be related to inadequate primary

defenses (decreased ciliary action, stasis of respiratory secretions)
Evaluation criteria : identify interventions to prevent / reduce risk of
infection.

Interventions Rationale
a. Monitor vital sign closely a. During this period of time,
especially during initiation of potentially fatal complications
therapy. (hypotension / shock) may
develop.
b. Instruct patient concerning the b. Sputum be disposed of in a safe
disposition of secretions ( e. g. manner. Changes in
raising and expectoration versus characteristics of sputum reflect
swallowing) and reporting resolution of pneumonia or
changes in color amount, odor of development of secondary
secretions. infection.

4 Activity intolerance may be related to imbalance between oxygen supply and

demand.

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 Evaluation criteria : report / demonstrate a measurable increase in tolerance to
activity with absence of dyspnea, excessive fatigue, and vital signs within
patients normal range.

Interventions Rationale
a. Provide a quiet environment and a. Reduces stress and excess
limit visitors during acute phase as stimulations, promoting rest.
indicated. Encourage us of stress
management and diversion
activities as appropriate.
b. Assist the patient to assume b. Patient may be comfortable with
comfortable position for rest and / head of bed elevated, sleeping in a
or sleep. chair, or resting forward on over
bed table with pillow support.

5 Pain ( acute ) may be related to inflammation of lung parenchyma and

persistent coughing.
Evaluation criteria : Verbalize relief / control of pain.

Intervention Rationale
a. Determine pain characteristics, e. a. Chest pain, usually present to
g. sharp constant stabbing. some degree with pneumonia.
Investigate changes in character / May also Nereid the onset of
location / intensity of pain. complication of pneumonia such
as pericarditis and endocarditis.
b. Monitor vital sign b. Changes in near rate of BP may
indicate that the patient is is
experiencing pain especially when
order reasons for changes in vital
signs have been ruled out.
c. Provide comport measure, e.g. c. Non analgesic measure
back rubs, change of position, administered with a gentle touch
quiet music / conversation, can alleviate discomfort and
relaxation / breathing exercises. augment therapeutic effect of
analgesics.

6 Nutrition, less than body requirement , high risk for may be related to
increased metabolic needs secondary to fever and infectious process.
Evaluation criteria : demonstrate increased appetite and maintain / regain
desired body weight.
Intervention Rationale
a. Identify factors that are a. Choice of interventions is
contributing to nausea / vomiting, dependent on the underlying cause
e.g. copious sputum, aerosol of the problem.
treatments, severe dyspnea, pain.
b. Schedule respiratory treatments at b. Reduces effects of nausea

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 least 1 hour before meals. associated wit these treatments.
c. Auscultation, for bowel sounds. c. Bowel sound diminished / absent
Observe / palpate for abdominal if the infectious process is severe /
distention. prolonged.
d. Provide small, frequent meals. d. These measure may enhance
intake even though appetite may
be slow to return.

7 Fluid volume deficit, high risk for may be related to excessive fluid loss
( fever, profuse diaphoresis, mouth breathing / hyperventilation, vomiting )
Evaluation criteria : demonstrate fluid balance.

Interventions Rationale
a. Assess vital sign a. Elevated temperature / prolonged
fever increased metabolic rate and
fluid loss through evaporation
orthostatic BP changes and
increasing tachycardia may
indicated systemic fluid deficit.
b. Assess skin turgor, moisture of b. Indirect indicator of adequacy of
mucus membranes ( lips, tongue ) fluid volume.
c. Note reports of nausea / vomiting. c. Presence of these symptom
reduces intake

8 Knowledge deficit ( learning need ), regarding condition and treatment needs

may be related to altered recall.
Evaluation criteria : verbalize understanding of condition, disease process and
treatment

Interventions Rationale
a. Review normal lung function, a. Promotes understanding of current
pathology of condition. situation and important of
b. Provide information in written as cooperating with treatment
will as verbal form. regimen.
c. Stress importance of continuing b. Fatigue and depression can effect
effective coughing / deep ability to assimilate information /
breathing exercise. follow medical regimen.
c. During initial 6-8 weeks after
discharge patient is at greatest risk
for recurrent of pneumonia.

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 BIBLIOGRAPHY

Campbell, cline . 1989. Nursing diagnosis Dan intervention in nursing

practice second edition. Canada: A Wiley medical publication.

Doenges, Marilynn E. 1989. Nursing care plans edition 3.

United stated of America: F.A. Davis company.

Thompson, June M. 1986. Clinical nursing 3. United states of America

the C. V; Mosby company.