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NURSING CARE PROCESS

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION


DIAGNOSIS EXPLANATION

Objective cues: Impaired gas In pneumonia, >After 2 hours  Assessed  Manifestations of The client
exchange oxygen is the gas of nursing respiratory rate, respiratory distress demonstrated
> Use of related to exchange affected interventions, depth & ease. are dependent on improved ventilation
accessory muscles alveolar most; therefore, the client will inactive of the degree and oxygen tissues
when breathing capillary hypoxemia is the demonstrate of the lung and absence of
membrane primary problem. improve involvements in symptoms of
>crackles on lower changes. Carbon dioxide ventilation & underlying general respiratory distress as
lobe of the lungs retention is common oxygen tissues health status. manifested by the
in pneumonia. & absence of (Pediatric Nursing decrease in apical
>non – productive symptoms of Care Plan, Axton, et. pulse- 132 beats per
cough respiratory Al, pg. 296) minute and respiratory
(Medical-Surgical distress. rate of 48 breaths per
>tachypneic- 58 Nursing  Monitored heart  Tachycardia is usually minute.
breath per minute Pathophysiological rate. present as a result of
Concept, pge 496) fever dehydration but
>mouth breather may represent a
response to
>cyanosis in lips hypoxemia. (Pediatric
and nail bed Nursing Care Plan,
Axton, et. Al, pg.
>nasal flaring 296)

>dyspnea  Monitored body  A fever as early


temperature as increase metabolic
>result of CXR, indicated. demands & oxygen
Pneumonia in Assisted the consumption & alters
inner lung zone comfort cellular oxygenation.
measures to (Pediatric Nursing
>restlessness reduce fever & Care Plan, Axton, et.
chills; addition or Al, pg. 297)
removal of
bedcovers,
comfortable room
temp.

 Observed color of  Cyanosis of nail beds


the skin & nail may represent
bed, noting vasoconstriction or the
presence of body’s response to
peripheral fever with chills;
cyanosis with however, cyanosis of
central cyanosis. skin membranes
around the mouth is
indicative of systemic
hypoxemia. (Pediatric
Nursing Care Plan,
Axton, et. Al, pg.
297)

 Maintained bed  Prevents over


rest. exhausting & reduces
oxygen consumption
demands to facilitate
resolution of infection.
(Pediatric Nursing
Care Plan, Axton, et.
Al, pg. 297)

 Elevated heads  These measures


and encouraged promote maximal
frequent position inspiration; enhance
changes. expectorant of
secretions to improve
ventilation. (Pediatric
Nursing Care Plan,
Axton, et. Al, pg.
297)

 Back tapping  Chest physiotherapy


performed after helps to aid
each immobilization of
nebulization. secretions. (Nursing
Care Plan,7th edition,
Doenges, et.a pg
108l)

 Instructed the  Discharges from the


mother to have nebulizer are often
oral care to her foul tasting and
baby after each smelling. (Nursing
nebulization. Care Plan, 6th
edition,
Gulanick/Myers pg.
480)
 Administered  Relaxes bronchioles
medication as by acting on beta –
indicated. adrenergic receptors.
-Salbutamol (MIMS 7th edition
sulfate 2006 pg 78)
-brochodilator