Pneumonia: Nursing Care Plan PDF

## Pneumonia ### Definition Inflammation of the lungs caused by bacterial, viral or fungal infection. It is a serious infection or inflammation in which the air sacs (alveoli) fills with pus and other liquid. ### Types 1. Lobar: Is an infection that only affects a single lobe or section of lung 2...

## Pneumonia ### Definition Inflammation of the lungs caused by bacterial, viral or fungal infection. It is a serious infection or inflammation in which the air sacs (alveoli) fills with pus and other liquid. ### Types 1. Lobar: Is an infection that only affects a single lobe or section of lung 2. Interstitial: Involves the areas between alveoli 3. Bronchopneumonia: Most common infection of terminal bronchioles that extends into the surrounding alveoli resulting in patchy consolidation of the lung. ### Signs and Symptoms * Cough * Difficulty breathing * Fever * Tachypnea * Tachycardia * Chest pain * Heavy sweating * Bluish color of lips and fingernails * Loss of energy * Shaking chills * Cyanosis ### Severity * Mild: SpO2 (92%) * Moderate: SpO2 (83-91%) * Severe: Less than 80% ### Pathophysiology 1. Infection to the lung initiates 2. Inflammatory response initiates 3. Alveolar edema: Exudate formation 4. Alveoli fill with serous exudate, blood cells, fibrin and bacteria ### Nursing Care Plan for a Child with Pneumonia #### Problem | Nursing Diagnosis | Goal/Objective | Implementation | Rationale | Evaluation ------- | -------- | -------- | -------- | -------- | -------- Ineffective airway clearance | Ineffective airway clearance related to inflammation and increased secretions as evidenced by presence of secretions, productive cough, tachypnoea and increased work of breathing. | Maintain patent airway. | Position the child with airway open (sniffing position if supine). Humidify oxygen and ensure adequate fluid intake (intravenous or oral). Suction with bulb syringe or via nasopharyngeal catheter as needed. In older child, encourage expectoration of sputum with coughing. Perform chest physiotherapy if ordered. | To promote adequate ventilation as open airway allows adequate air entry. To help liquefy secretions for ease in clearance. To promote clearance of secretions. To promote airway clearance. To mobilize secretions. | Patent airway maintained as evidenced by child being free of secretions, easy work of breathing and respiratory rate parameters for age. Ineffective breathing pattern | Ineffective breathing pattern related to inflammatory or infectious process as evidenced by tachypnea, increased work of breathing and nasal flaring. | The child will exhibit adequate ventilation. | Assess respiratory rate, breath sounds, and work of breathing frequently -4 hourly. Use pulse oximetry to monitor oxygen saturation. Position child for comfort with open airway and room for lung expansion and use pillows or padding if necessary to maintain position. Administer supplemental oxygen. Encourage coughing with deep breathing in older | To ensure progress with treatment and note deterioration early. To note adequacy of oxygenation and detect hypoxaemia early. To ensure optimal ventilation. To improve oxygenation and enhance the child’s participation. | Child exhibits adequate ventilation evidenced by respiratory rate within parameters for, age, easy work of breathing, clear breath sounds and oxygen saturation greater than 94%. #### Interventions * Elevate the head of bed and change position frequently * Use oxygen, humidifier (nebulizers) * Suction for secretions when needed * Administer prescribed medication * Frequent oral and nasal hygiene * Apply cold compress to reduce fever #### Health Teaching * Maintain body rest * Teach and assist patient with often deep breathing exercise #### Diagnoses 1. Chest consolidation 2. Clinical Manifestation 3. OBC, WBC, SpO2, Spesis 4. ABG 5. Pulse Oximeter 6. CRP #### Treatment According to Severity Level and Type * Mechanical ventilation * Bronchodilators * Fluids * Oxygen * Antipyretics