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Nursing Interventions for Pneumonia Pneumonia, acute infection of the lung parenchyma, interstitial lung tissue in w hich fluid

and blood cells escape into the alveoli. that often impairs gas excha nge. Pneumonia classified in several ways. Based on microbiological etiology origin: Viral Bacterial Fungal Protozoa Mycobacterium Mycoplasmal Rickettsial Based in location, pneumonia can be classified: Bronchopneumonia, Bronchopneumonia involves distal airways and alveoli Lobular pneumonia or lobar pneumonia. In this pneumonia involves part of a lobe; and lobar pneumonia, an entire lobe The infection is also classified as one of three types: Primary pneumonia Primary pneumonia results directly from inhalation or aspiration of a pathogen, such as bacteria or a virus; it includes pneumococcal and viral pneumonia. Secondary pneumonia Secondary pneumonia may follow initial lung damage from a noxious chemical or ot her insult (superinfection) or may result from hematogenous spread of bacteria f rom a distant area. Aspiration pneumonia Aspiration pneumonia results from inhalation of foreign matter, such as stomach contents vomitus or food particles, into the bronchi. It s more likely to occur in elderly or debilitated patients, those receiving nasogastric tube feedings, hig her prevalence those with an impaired gag reflex, poor oral hygiene, or a decrea sed level of consciousness. Nursing Interventions for Pneumonia Intervention and Rationale: I. Assess for: Respiratory status including rate, depth, ease, shallow or irregular breathing, dyspnea, use of accesory muscles, and diminished breath sounds, rhonchi or crack les on auscultation - provides data baseline. Changes in mental status, skin color, cyanosis - indicates possible decrease in oxygenation. Quality of cough and ability to raise secretions including consistency and chara cteristics od sputum - removal of secretions prevents obstruction of airways and stasis leading to further infection and consolidation of lungs; clearing airway s facilitates breathing. II. Monitor, record, describe: Respiratory rate, quality and breath sounds q2-q4 - indicates airway resistance, air movement, severity of disease. ABGs, oximeter reading - decreased oxygen levels result in hypoxemia. III. Administer: Oxygen therapy via cannula - maintain optimal oxygen level. Antitussives/expectorants (terpin hydrate, guaifenesin) - acts on bronchial cell

s to increase fluid production and promote expectoration; guaifenesin reduces su rface tension of secretions; both relieve non-productive cough Mucolytic (acetylcysteine) - decrease viscosity of mucus for easier removal. Antibiotic (ampicillin, cephalexin) - acts by binding to cell wall organisms pre venting synthesis and destroying pathogens. IV. Perform or Provide: Position of comfort in semi or high fowlers and change position q2h - facilitate s breathng and allows for full expansion of lungs. Encourage coughing if sounds is moist; if dry and hacking, increase fluid intake and administer cough suppresant - reduces continual irritation to throat and li quefies secretions. Coughing and deep breathing exercise q2h; use incintive spirometer 5-10 breaths if tolerated - coughing clears airway by propelling secretions to mouth deep bre athing promoes ventilation and prolongs expiratory phase. Assist with coughing by splinting chest; humidified air with cool mist - loosens seretions and improves ventilation, moistens mucous membranes Postural drainage and percussion PRN - mobilizes secretion. Suction secretions if cough ineffective - removal if unable to bring up secretio ns. Oral care after expectoration and provide tissues and bag for disposal - promote s comfort and prevents transmission of organisms to others. Nursing Interventions: Pneumonia 1. Maintain a patent airway and adequate oxygenation. 2. Obtain sputum specimens as needed. 3. Usesuctionif the patient can t produce a specimen. 4. Provide a high calorie,high protein dietof soft foods. 5. To prevent aspiration duringnasogastric tubefeedings, check the position o f tube, and administer feedings slowly. 6. To control the spread of infection, dispose secretions properly. 7. Provide a quiet, calm environment, with frequent rest periods. 8. Monitor the patient s ABG levels, especially if he s hypoxic. 9. Assess the patient s respiratory status. Auscultate breath sounds at least every 4 hours. 10. Monitor fluid and intake output. 11. Evaluate the effectiveness of administered medications. 12. Explain all procedures to the patient and family. Nursing Care Plan for Pneumonia Definition Pneumonia is a breathing (respiratory) condition in which there is an infection of the lung. Causes Pneumonia caused by bacteria tends to be the most serious kind. In adults, bacte ria are the most common cause of pneumonia. The most common pneumonia-causing germ in adults is Streptococcus pneumoniae (pn eumococcus). Atypical pneumonia, often called walking pneumonia, is caused by certain other b acteria. Pneumocystis jiroveci pneumonia is sometimes seen in people whose immune system is not working well. Many other bacteria can also cause pneumonia.

Viruses are also a common cause of pneumonia, especially in infants and young ch ildren. Signs and Symptoms Symptoms of pneumonia caused by bacteria usually come on quickly. They may inclu de: imes. Cough. Fever. Fast breathing and feeling short of breath. Shaking and "teeth-chattering" chills. You may have this only one time or many t Chest pain that often feels worse when you cough or breathe in. Fast heartbeat. Feeling very tired or feeling very weak. Nausea and vomiting. Diarrhea.

Pathogenesis Pathogenesis of pneumonia include interactions between microorganisms (MO) cause s that go through various avenues, with patient endurance. Germs reach the alveo li by inhalation, aspiration of oropharyngeal bacteria, hematogenous spread from another focus of infection, or direct spread from the site of infection. At the lower respiratory tract, the bacteria encounter in the form of immune defense s ystem mukosilier, cellular resistance alveolar macrophages, bronchial lymphocyte s and neutrophils. Also humoral immune IgA and IgG from bronchial secretions. The occurrence of pneumonia depends on the virulence of MO, the ease and extent of endurance. Nursing Care Plan for Pneumonia Assessment - Nursing Care Plan for Pneumonia A. Subjective Data Sudden onset of fever accompanied by convulsions Clients complained weak Shortness of breath Complaining tired when on the move Insomnia Coughing up phlegm Nausea, vomiting, no appetite Sometimes diarrhea Weight loss

B. Objective Data Cyanosis of the mouth and nose Dry skin with poor turgor Clients look tired Breathing fast (tachypnea) and shallow accompanied nostril Dyspnoea, bronchial breath sounds, crackles. Breathing using accessory muscles

Dullness found in percussion Awareness of decreased / lethargy Communication substandard Orientation to person, place and time poor Laboratory results: leukocytosis, increased erythrocyte sedimentation rate, abno rmal blood gas analysis Photos chest: there are patches lobe infiltrates. Nursing Diagnosis for Pneumonia 1.Ineffective Airway Clearancerelated to inflammation, the accumulation of secret ions, characterized by: Tachypnea / rapid breathing, shallow accompanied nostrils. Bronchial breath sounds, crackles wet, accessory muscle use. Dyspnoea, cyanosis Cough with sputum production.

2.Impaired Gas Exchangerelated to alveolar capillary membrane changes characterized by: Dyspnea, cyanosis Tachycardia Restless

3.Imbalanced Nutrition Less Than Body Requirementsrelated to the lack of oral int ake characterized by: Decreased appetite Weight loss: weakness, decreased muscle tone

4.Hyperthermiarelated to inflammatory processes characterized by: Increased body temperature

Outcome : 1. Effective airway, with the following criteria: Adequate ventilation No buildup

2. Optimal gas exchange, adequate oxygenation to the tissue, with the following criteria: No dyspnoea No cyanosis

3. Clients can meet the needs adequate nutrition, with the following criteria: Increased appetite Maintain / increase weight

4. No fever with the following criteria: Body temperature fell within normal limits

Nursing Interventions for Pneumonia Ineffective Airway Clearance Independent: Assess the frequency / depth of breathing and chest movement R :/ takipneu, shallow breathing, and asymmetrical chest movements often occur b ecause of discomfort or movement of the chest wall and lung fluid. Help patients breathing exercises frequently. Show / aids patients studied did c ough, such as chest presses and effective cough while sitting high R :/ Breath in facilitating the maximum expansion of the lung / airway smaller. Coughing is a natural cleaning mechanism of airway / help the cilia to maintain a patent airway. Emphasis lower chest discomfort and breathing effort seating po sition allows deeper and more powerful. Exploitation as indicated R :/ Stimulate cough or mechanical airway clearance in patients who are unable t o perform because of ineffective cough or a decreased level of consciousness. Give fluids at least 2500 ml / day (unless contraindicated). Offer warm water ra ther than cold. R :/ liquids (especially warm) mobilize and remove secretions. Collaboration Assist to monitor the effects of treatment and physiotherapy another nebuliser. For example, an incentive spirometer, blowing bottles, percussion, postural drai nage. Take action in between meals and limit fluids when possible. R :/ Facilitate dilution and removal of secretions. Postural drainage is not eff ective in causing interstitial pneumonia or alveolar exudate or damage. Coordina tion of treatment / schedule and oral input vomit degrade because of cough, sput um spending. Give medications as indicated: mucolytics, expectorants, bronchodilators, analge sic R :/ equipment for lowering the mobilization of secretions bronchospasm. Analges ics are given to improve the cough by decreasing discomfort but should be used w ith caution, because it can reduce the effort cough / depress respiration.

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