NURSING CARE PLAN

Nursing
Diagnosis
Analysis Goals & Objectives
Nursing
Interventions
Rationale Evaluation
Ineffective
airway clearance
related to
pneumonitis as
manifested by
Subjective:
All of
Vinalons
children have
asthma since
birth but it
worsens due
to their living
place.
The father
also has a
history of
asthma in his
family
According to
Mrs. Vinalon,
her daughter
had fever, cold
and coughs
for three
days.
ita has been
Pneumonia is an inflammation
of the lung, usually caused by
an infection. Three common
causes are bacteria, viruses
and fungi. You can also get
pneumonia by accidentally
inhaling a liquid or chemical.
People most at risk are older
than 65 or younger than 2
years of age, or already have
health problems.
E!IO"OG#
Pneumonia is a very common,
serious illness and aects about !
out o !"" #eo#le eac$ year% It is
caused by many dierent
or&anisms and can ran&e in
seriousness rom mild to lie'
t$reatenin& illness% ($ere are
dierent cate&ories o #neumonia%
PATHOPHYSIOLOGY:
There are diferent
categories of pneumonia.
Two of these types are
hospital-acquired and
community-acquired.
Common types of
community-acquired
pneumonia are
pneumococcal pneumonia
and Mycoplasma
pneumonia. In some
people, particularly the
elderly and those who are
debilitated, pneumonia
may follow infuena.
!ospital-acquired
Goal
)y *#m today +Se#t%
!,, -""./, t$e
#atient0s air1ay is
ree rom secretions
as evidenced by
clear lun& sound%
Objectives
Ater nursin&
interventions:
!% t$e client0s
oral #$aryn2
1ill be
suctioned
-% t$e client
1ould
receive bac3'
ta##in&
Suction t$e
c$ild0s oral
#$aryn2
Perorm bac3'
ta##in&
Suctionin& is used to
remove mucus or
saliva rom your
baby0s nose, mout$
and t$roat%
111%s#$%unc%edu4oce4#$nceac4
baby&uide4suctionin&%#d
)ac3'ta##in& over
con&ested #art lun&
areas can
mec$anically
dislod&e tenacious
5oes t$e client0s
oral #$aryn2 $ave
been suctioned6
7yes 7no 1$y6
5oes t$e client
able to receive
bac3'ta##in&6
7yes 7no 1$y6
diagnosed to
have
!ronchopneu
monitis.
8bjective:
"#$ productive
cough
"#$ colds
"#$ whistling
sounds on
thora%
pneumonia tends to be
more serious because
defense mechanisms
against infection are often
impaired. "ome of the
speci#c pneumonia-related
disorders include$
aspiration pneumonia,
pneumonia in
immunocompromised host
and %iral pneumonia
SIGNS & SYMPTOMS:
Cough &with mucus-li'e,
greenish, or pus-li'e
sputum
chills with sha'ing (, fe%er,
easy fatigue, chest pain
&sharp or stabbing
increased by deep
breathing or increased by
coughing(, headache, loss
of appetite, nausea and
%omiting, general
discomfort, uneasiness, or
ill feeling &malaise(, )oint
stifness &rare(, muscular
stifness &rare(, rales
*dditional symptoms that
may be associated with this
disease$ shortness of
breath, clammy s'in, nasal
faring, coughing up blood,
tacypnea, apnea, an+iety,
stress, and tension,
,% ($e client
1ill be in
semi'o1ler
or $i&$'
o1ler
#osition%
*% t$e client
1ill receive
t$e
#rescribed
medications
Position t$e client
in semi'o1ler or
$i&$'o1lers%
Administer t$e
#rescribed
antibiotics and
e2#ectorants%
secretions rom t$e
bronc$ial 1alls%
9undamentals o Nursin&,
:o;ier,et% al% #% !,",'!,"*
Clients 1it$
increased #ulmonary
secretions are able to
breat$e better 1$en
u#ri&$t because
abdominal or&ans
are lo1er and t$ere
is &reater room or
lun& and
dia#$ra&matic
e2cursion%
9undamentals o Nursin&,
:o;ier,et% al% #% !!"<
Positionin&
acilitates clearin&
and mobili;ation o
secretion%
Nursin& Care Plans, =
t$
ed%
Gulanic3,et% al% #% *"=
*ntibiotics are
powerful
medicines that
#ght bacterial
infections. Cough
5oes t$e client
$ave been
#ositioned in a
semi'o1ler or
$i&$'o1ler0s
#osition6
7yes 7no 1$y6
5oes t$e client
receive $er
#rescribed
medicines6
abdominal pain .
e+pectorants help
,brea' up-
mucus, ma'ing it
more liquid and
easier to
e+pectorate.
9undamentals o Nursin&,
:o;ier,et% al% #% !,",
7yes 7no 1$y6