Bronchopneumonia Care Plan 52712q

1 Ineffective Airway Clearance Mucus is produced at all times by the membranes lining the air ages. When the membranes are irritated or inflamed, excess mucus is produced and it will retain in tracheobronchial tree. The inflammation and increased in secretions block the airways making it difficult for the person to maintain a patent airway. In order to expel excessive secretions, cough reflex will be stimulated. An increased in RR will also be expected as a compensatory mechanism of the body due to obstructed airways.

Assessment

Nursing Diagnosis

Planning

Ineffective airway clearance r/t accumulation of tracheobronchial secretions

SHORT TERM:

Nursing Interventions

Rationale

Expected Outcome

flaring

> Monitor and record vital > To obtain baseline SHORT TERM: signs data After 3-4 hours of After 3-4 hours of NI, > Assess patient’s > To know the NI, pt.’s SO will be pt. shall have condition. patient’s general able to demonstrate demonstrated improve condition improve airway airway clearance AEB > Elevate head of bed and clearance AEB reduction of congestion encourage frequent > To promote

> With rales on

congestion with

both lung fields

breath sounds clear > Keep back dry and and RR improve loosen clothing

S>(none) O> >Restlessness with nasal

> warm, flushed skin >minimal colorless nasal secretions >tachypnea AEB RR=53bpm

reduction of

position changes.

maximal inspiration, with breath sounds clear and RR improve enhance expectoration of

>Auscultate breath sounds improve ventilation After 2-3 days of NI, pt. shall have established and assess air movement > To promote After 2-3 days of and maintained airway comfort and NI, pt. will be able >Monitor child for feeding patency. intolerance and abdominal adequate ventilation to establish and distention maintain airway > To ascertain status patency. and to note progress > Instruct the SO to LONG TERM:

provide an increased fluid intake for the child

>DOB > Instruct the SO to

> To avoid compromising the airway

>tachycardia

provide

>irritability

adequate rest periods for

>chest

the child

indrawing

> Give expectorants and

>cough

bronchodilators as ordered. oxygen demands for

>cyanosis

> ister oxygen

>noisy breathing >pallor >changes in RR and rhythm >risk for infection

LONG TERM:

secretions in order to

> To help liquefy the secretions > Rest will prevent fatigue and decrease metabolic demands

therapy and other

> To further

medications as ordered.

mobilize secretions > To clear airway when secretions are blocking the airway indicated to increase oxygen saturation.

>orthopnea >tachypnea

2 Impaired Gas Exchange The exchange in oxygenation and carbon dioxide gases is impeded due to the obstruction caused by the accumulation of bronchial secretions in the alveoli. Oxygen cannot diffuse easily.

Assessment

S>O O> Pt manifested: >Restlessness >with nasal flaring > With rales on both lung fields Patient may manifest: > Metabolic acidosis

Nursing Diagnosis Planning

Nursing Interventions

Rationale

Expected Outcome

Impaired gas exchange related to inflammation of airways and accumulation of sputum affecting O2 and CO2 transport

> Monitor and record vital signs

> To obtain baseline data

SHORT TERM:

> Observe color of skin,

> Cyanosis of nail

SHORT TERM: After 6 hours of NI, pt will be able to demonstrate improvement in gas exchange AEB a to normal LONG TERM:

> Elevate head of bed and

After 1-2 days of NI, pt will be able to demonstrate

>Keep back dry. > Promote

improved ventilation and adequate rest periods adequate oxygenation of tissues AEB absence of >Change position q 2 hrs.

cyanosis

distress.

vasoconstriction or the body’s response to fever/ chills

encourage frequent position > To promote maximal changes.

symptoms of respiratory

>tachypnea

beds, noting presence of

peripheral cyanosis. decrease in respiratory rate

> Circum-oral

>DOB

mucous membranes and nail beds may represent

free > Suction secretions PRN

expectoration of improve ventilation

exchange AEB a decrease in respiratory rate to normal LONG TERM: Patient shall ventilation and adequate oxygenation

>To avoid coughing > Rest will prevent oxygen demands for metabolic demands >To promote drainage

> To reduce irritant

> ister oxygen therapy effects on airways as ordered.

improvement in gas

secretions in order to demonstrate improved

>Instruct SO to increase fluid of secretions intake of the child

demonstrate

inspiration, enhance

fatigue and decrease > Keep environment allergen

Patient shall

> To clear airway when secretions are blocking the airway indicated to increase oxygen saturation >To liquefy secretions > O2 therapy is indicated to increase oxygen saturation

of tissues AEB absence of symptoms of respiratory distress.

3 Hyperthermia A person experiences hyperthermia due to the inflammatory process wherein the body tries to compensate and adapt to the dse. condition. As a defense mechanism, the body produces host inflammatory cells causing fever. Interluekin-1 function as a pyrogens that acts on the hypothalamus. 1L-1 act as a hormone where it is carried by the inflammation site of production to the CNS, where it acts directly on the hypothalamic thermal control center, thus elevating the thermal set point.

Assessment

S>Ø

Nursing Diagnosis Planning

Nursing Interventions

Hyperthermia

> Assess pt’s condition and >To have baseline monitored vital signs. data.

Short-term: After 3 hours of nursing

O> The pt

interventions the pt’s

manifested

Rationale

by evaporation and

>Instruct the SO to provide decrease to normal limits an increase fluid intake for from 37.9 to 37.5ºC the child.

temp. at 37.9ºC

Long-term:

>Skin is warm to

provide blanket for the child.

After 3 days of nursing

>With flushed

interventions the pt will be >Maintain bed rest and able to maintain a temp.

adequate rest periods.

within normal range . >Ask SO to provide high

>Increase in RR

conduction.

>Maintain patent airway and

touch.

skin.

Short-term: After 3 hours of

>Perform tepid sponge bath >To promote heat loss

temperature will be

>Increase body

Expected Outcome

caloric diet for the child The patient may

nursing interventions the pt’s temperature shall have decreased

>To

to normal limits from

circulating volume

37.9 to 37.5ºC

and tissue perfusion. >To promote pt’s safety and to avoid chills.

Long-term: After 3 days of nursing interventions the pt shall be able to

>To reduce metabolic maintain a temp. within normal range . demands/ Oxygen

>ister antipyretics as consumption.

manifest:

ordered. >chills

>To meet increase metabolic demands.

>lack of appetite >To lower the temperature.

4 Disturbed Sleeping Pattern Sleep is disrupted when a person experiences unpleasant sensation arising from difficulty of breathing and ineffective expectoration of mucus secretions in the airways.

Assessment

S > The mother verbalized that her child often wakes up during midnight. O> patient manifested: >changes in

Nursing Diagnosis

Disturbed Sleep Pattern r/t difficulty of breathing

Planning

Nursing Interventions

Short Term:

-monitor vital signs

Rationale

Expected Outcome

-to have a comparable Short Term: baseline data After 3 hours of nursing -encourage SO to increase After 3 hours of -to promote interventions the SO will intake of warm milk for the nursing interventions drowsiness be able to verbalize child the SO shall have understanding of sleep disturbance and identify interventions to promote sleep for the child.

- provide a quiet environment for the child

-to promote comfort verbalized and relaxation /sleep understanding of sleep

periods for the child disturbance and identified -instruct SO to provide a dim

behavior (irritability) >restless >DOB

Long Term:

environment for the child

After 3 days of nursing

>advise SO to provide

for the child

promote sleep for the child.

interventions, SO will be blanket for the child

>to avoid chills and to

able to report

promote comfort

Long Term:

> to maximize lung

After 3 days of

improvement in sleep

>instruct SO to elevate HOB

pattern of the child.

>nasal flaring

-to promote comfort interventions to

expansion of the child nursing interventions, and to decrease DOB the SO shall have

The patient may

reported improvement

manifest:

in sleep pattern for the >lack of interest

child

in food >weight loss >DOB >tachypnea

5 Risk for Infection Immuno-suppression due to decrease in hemoglobin, leukopenia, and suppress inflammatory response gives a greater opportunity for pathogenic bacteria to invade and inoculate in a specific body part of a susceptible human body. Thus, leading to a further damage or infection.

Assessment

Nursing Diagnosis

Planning

S> 

Risk for infection (spread) related to inadequate secondary defenses(decrease hemoglobin, hematocrit and immunosuppression)

Short term:

O>the patient manifested >fever of 38.3ºC

interventions the patient’s S.O will verbalize her understanding of individual causative/risk factors and demonstrate

adventitious

lifestyle changes to

sounds in both

prevent further infection.

>productive cough

Long term:

concerning about the

disposal of secretions

disposition of secretions and and to assess for the report changes in color,

resolution of

amount and odor of

pneumonia or

secretions.

development of secondary infection.

Expected Outcome

her understanding of individual causative/risk factors and demonstrate lifestyle changes to prevent further infection.

interventions the patient

infection.

spread of infection.

shall have verbalized

perform good hand washing 3. To reduce spread or acquisition of

will be free from possible

may manifest:

2. To promote safety

After 1-2 days of nursing techniques.

color

The patient

2. Instruct the S.O

3. Encourage the SO to

>skin pale in

>restlessness

Rationale

1. Monitor v/s closely, 1. To know potential Short term: especially during initiation fatal complication After 6 hours of nursing of therapy. The patient’s S.O that may occur.

>presence of

lung field.

Nursing Interventions

4. Encourage adequate rest. 5. Stress the importance of increasing the child’s nutritional intake. 6. Encourage the mother to keep an eye to the baby and

>activity

observe anything that the

intolerance

baby is putting in his mouth.

4. To enhance fast recovery and regain strength. 5. A good nutritional intake can strengthen body immune defense. 6. To prevent entry of

Long term: The patient shall have been free from possible spread of infection.

>fever

7. Ask SO to provide a good microbes. hygiene for the child. (bed

>cough and

bath)

colds

8. Ask SO to provide an

>pallor

adequate safe drinking

>cyanosis

milk/water for the child

>DOB

9. Ask SO to keep the child warm and to provide blanket

>tachypnea

8. To prevent GI disturbance 9. To avoid chills and to prevent the child from having fever 10. To combat

10. ister >tachycardia

7. To eliminate MO

antimicrobials as ordered.

microbial pneumonias.

6 Risk for Imbalanced Nutrition A disruption in the mucosal barrier causes gastric acid to come into with gastric tissues and damage them causing irritation or inflammation. This leads to alteration of the mucosal barrier impairing the absorption process with in the stomach and putting the patient at high risk for imbalance nutrition less than body requirements.

Assessment

Nursing Diagnosis

Planning

Nursing Interventions

Rationale

Expected Outcome

S= The mother

Risk for

SHORT TERM:

-Monitor vital signs

- To have baseline

SHORT TERM:

verbalized an

imbalanced

evident weight

nutrition, less than

loss in her child.

body requirement

O= Patient manifested: >pallor >lack of appetite >lack of interest to food offered

related to decrease nutrient absorption

After 3 hours of Nursing - assess for difficulty of

Interventions, the SO will swallowing and the ability to - can be factors that be able to verbalize understanding of causative factors when known and necessary interventions for the child. LONG TERM: After 2 days of Nursing Interventions, the patient

>type of food

will be able to

cannot meet the

demonstrate behaviors,

metabolic

lifestyle changes to regain

demand of the

and/or maintain

child (powder

appropriate weight.

milk, milo, chips) The patient may manifest: >constipation >diarrhea

data

swallow - encourage family to prepare food of patient’s preferences - develop meal plan with the patient - ask the SO to the child during meal time

can affect ingestion and causative of altered nutrition

The SO shall have verbalized understanding of causative factors when known and

- to maintain adequate necessary caloric intake - to meet the nutritional needs of the client - to enhance intake

interventions for the child. LONG TERM: The client shall have demonstrated behaviors, lifestyle changes to regain and/or maintain appropriate weight.

>weight loss >pallor