Nanda - Nursing Care Plan

Acute Pain - Nursing Care Plan for Pneumonia

Pneumonia is an inflammation of the lungs that is usually caused by infection.

The most common causes of pneumonia are infections caused by:
  • bacteria - the most common cause of pneumonia in adults
  • viruses - often responsible for pneumonia in children
  • mycoplasma - organisms that have characteristics of bacteria and viruses that cause milder infections
  • opportunistic organisms - a threat to people with vulnerable immune systems (e.g., Pneumocystis carinii pneumonia in people who have AIDS)

A person who has a higher risk of pneumonia:
  • is under one year of age or over the age of 65
  • is a smoker
  • has a cold or flu
  • has a weak immune system due to cancer therapy, HIV infection, or other disease
  • is undergoing surgery
  • has a problem with alcohol use
  • has a chronic illness such as heart disease, lung disease, or diabetes
  • has a chronic lung disease, such as asthma or chronic obstructive pulmonary disease


Nursing Diagnosis for Pneumonia : Acute Pain related to inflammation of the lung parenchyma, cough settled

characterized by:
  • chest pain
  • headache
  • restless

Goal: pain can be resolved

Expected outcomes:
  • Say no pain / pain can be controlled
  • Shows relax, rest or sleep and increased activity appropriately.

Intervention and Rational:

Independent
  • Evaluation of patient response to activity. Note the report dyspnea. Increased weakness or fatigue, and changes in vital signs during and after activity.
  • Determine the characteristics of the pain, ie sharp, constant, stabbed, explore the changing character / location / intensity of pain
  • Monitor vital signs
  • Provide convenient measures, such as back massage, change of positions, music, quiet / conversation, relaxation / breathing exercises.
  • Advise and assist the patient in mechanical chest compressions during episodes of coughing

Collaboration
  • Give analgesic and antitussive as indicated

Rationale :
  • Setting abilities / needs and facilitate patient choice of intervention.
  • Chest pain, usually within a few degrees of pneumonia, pneumonia can also arise complications such as pericarditis and endocarditis.
  • Changes in heart rate or blood pressure showed that patients experiencing pain, especially when other reasons for changes in vital signs have been seen.
  • Non-analgesic action is given a touch slow to eliminate the discomfort and maximize the effects of analgesic therapy.
  • Tool to control chest discomfort while increasing the effectiveness of cough effort.
  • These drugs can be used to suppress non-productive cough / paroksimal convenience / rest.