Acute Pain - Nursing Care Plan for Pneumonia

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.

Ineffective Airway Clearance NCP Pneumonia

Ineffective Airway Clearance NCP Pneumonia

Ineffective Airway Clearance NANDA Definition : : Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

Pneumonia is a lung infection that can be caused by different types of microorganisms, including bacteria, viruses, and fungi.

Some cases of pneumonia are contracted by breathing in small droplets that contain the organisms that can cause pneumonia. These droplets get into the air when a person infected with these germs coughs or sneezes. In other cases, pneumonia is caused when bacteria or viruses that are normally present in the mouth, throat, or nose inadvertently enter the lung.

Symptoms of pneumonia caused by bacteria usually come on quickly. They may include:

• Cough. You will likely cough up mucus (sputum) from your lungs. Mucus may be rusty or green or tinged with blood.
• Fever.
• Fast breathing and feeling short of breath.
• Shaking and "teeth-chattering" chills. You may have this only one time or many times.
• 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.

When you have mild symptoms, your doctor may call this "walking pneumonia."

Nursing Diagnosis for Pneumonia : Ineffective Airway Clearance

related to

• Pleuritic pain
• Decreased energy, fatigue
• Tracheal bronchial inflammation, edema formation, increased sputum production

Possibly evidenced by

• Abnormal breath sounds, use of accessory muscles
• Cough, effective or ineffective; with/without sputum production
• Dyspnea, cyanosis
• Changes in rate, depth of respirations

Outcomes

• Display patent airway with breath sounds clearing; absence of dyspnea, cyanosis.
• Identify/demonstrate behaviors to achieve airway clearance.

Interventions and Rationale :

1. Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds, e.g., crackles, wheezes.
R : Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasm/obstruction.

2. Assess rate/depth of respirations and chest movement.
R : Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung.

3. Assist patient with frequent deep-breathing exercises. Demonstrate/help patient learn to perform activity, e.g., splinting chest and effective coughing while in upright position.
R : Deep breathing facilitates maximum expansion of the lungs/smaller airways. Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airways. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort.

4. Force fluids to at least 3000 mL/day (unless contraindicated, as in heart failure). Offer warm, rather than cold, fluids.
R : Fluids (especially warm liquids) aid in mobilization and expectoration of secretions.

5. Monitor serial chest x-rays, ABGs, pulse oximetry readings.
R : Follows progress and effects of disease process/therapeutic regimen, and facilitates necessary alterations in therapy.