Pneumonia is the inflammation of the lung caused by bacteria in which the air sacs become filled with inflammatory cells and the lung becomes solid. The symptoms include those of any infection (fever, malaise, headache, etc.,) together with cough and chest pain.

It is estimated that, worldwide, some 4 million children under five years of age, die each year from acute respiratory infection (ARI) with the most of these deaths caused by pneumonia in developing countries.

In 1989, when the program for Control Acute Respiratory Infections (CARI) of the Philippines was launched, the death toll from pneumonia among children under the age of five years was 25,000. The latest statistics (2006) disclosed that almost 60 out of 1000 children under five children suffer from pneumonia and five in every 11,000 die from the disease. The Department of Health believes that if health workers used a standard method of detecting and managing ARI’s specially pneumonia, infant deaths could be cut by half, saving 50,000 lives a year. Pneumonia can be categorized by type of infiltrate: lobar pneumonia and bronchopneumonia.

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1 Ineffective Airway Clearance Mucus is produced at all times by the membranes lining the air passages. 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 Nursing Interventions

Rationale Expected Outcome

S>(none) O>

>Restlessness with nasal flaring

> With rales on both lung fields

> warm, flushed skin

>minimal colorless nasal

Ineffective airway clearance r/t accumulation of tracheobronchial secretions

SHORT TERM: After 3-4 hours of NI, pt.’s SO will be able to demonstrate improve airway clearance AEB reduction of congestion with breath sounds

> Monitor and record vital signs > Assess patient’s condition.

> Elevate head of bed and encourage frequent position changes.

> Keep back dry and loosen

> To obtain baseline data > To know the patient’s general condition

> To promote maximal inspiration, enhance expectoration of secretions in order to improve

SHORT TERM: After 3-4 hours of NI, pt. shall have demonstrated improve airway clearance AEB reduction of congestion with breath sounds clear and RR

secretions

>tachypnea AEB RR=53bpm

>DOB

>tachycardia

>irritability

>chest indrawing

>cough

>cyanosis

>noisy breathing

>pallor

>changes in RR and rhythm

>risk for infection

>orthopnea

>tachypnea

clear and RR improve

LONG TERM:

After 2-3 days of NI, pt. will be able to establish and maintain airway patency.

clothing

>Auscultate breath sounds and assess air movement

>Monitor child for feeding intolerance and abdominal distention

> Instruct the SO to provide an increased fluid intake for the child

> Instruct the SO to provide

adequate rest periods for the child

> Give expectorants and bronchodilators as ordered.

> Administer oxygen therapy and other medications as ordered.

ventilation

> To promote comfort and adequate ventilation

> To ascertain status and to note progress

> To avoid compromising the airway

> To help liquefy the secretions

> Rest will prevent fatigue and decrease oxygen demands for metabolic demands

> To further mobilize secretions

> To clear airway when secretions are blocking the airway

indicated to increase oxygen saturation.

improve

LONG TERM:

After 2-3 days of NI, pt. shall have established and maintained airway patency.

2 Impaired Gas ExchangeThe 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.

AssessmentNursing Diagnosis

PlanningNursing Interventions

RationaleExpected Outcome

S>O O> Pt manifested:

>Restlessness >with nasal flaring

> With rales on both lung fields

Patient may manifest:

> Metabolic acidosis

> Circum-oral cyanosis

>DOB

>tachypnea

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

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

LONG TERM:

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

improved ventilation and adequate oxygenation of tissues AEB absence of symptoms of respiratory distress.

> Monitor and record vital signs > Observe color of skin, mucous membranes and nail beds, noting presence of peripheral cyanosis.

> Elevate head of bed and encourage frequent position changes.

>Keep back dry.

> Promote

adequate rest periods

>Change position q 2 hrs.

> Keep environment allergen free

> Suction secretions PRN

>Instruct SO to increase fluid intake of the child

> Administer

> To obtain baseline data > Cyanosis of nail beds may represent vasoconstriction or the body’s response to fever/ chills

> To promote maximal inspiration, enhance expectoration of secretions in order to improve ventilation

>To avoid coughing

> Rest will prevent fatigue and decrease oxygen demands for metabolic demands

>To promote drainage of secretions

> To reduce irritant effects

SHORT TERM: Patient shall demonstrate improvement in gas exchange AEB a decrease in respiratory rate to normal

LONG TERM:

Patient shall demonstrate improved ventilation and adequate oxygenation of tissues AEB absence of symptoms

of respiratory distress.

oxygen therapy as ordered.

on airways

> 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

3 HyperthermiaA 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.

AssessmentNursing Diagnosis

PlanningNursing Interventions

RationaleExpected Outcome

S>Ø O> The pt manifested

>Increase body temp. at 37.9ºC

>Skin is warm to touch.

>With flushed skin.

Hyperthermia

Short-term: After 3 hours of nursing interventions the pt’s temperature will be decrease to normal limits from 37.9 to 37.5ºC

Long-term:

> Assess pt’s condition and monitored vital signs. >Perform tepid sponge bath

>Instruct the SO to provide an increase fluid intake for the child.

>Maintain patent

>To have baseline data. >To promote heat loss by evaporation and conduction.

>To support circulating volume and tissue

Short-term: After 3 hours of nursing interventions the pt’s temperature shall have decreased to normal limits from 37.9 to 37.5ºC

>Increase in RR

The patient may manifest:

>chills

>lack of appetite

After 3 days of nursing interventions the pt will be able to maintain a temp. within normal range .

airway and provide blanket for the child.

>Maintain bed rest and adequate rest periods.

>Ask SO to provide high caloric diet for the child

>Administer antipyretics as ordered.

perfusion.

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

>To reduce metabolic demands/ Oxygen consumption.

>To meet increase metabolic demands.

>To lower the temperature.

Long-term:

After 3 days of nursing interventions the pt shall be able to maintain a temp. within normal range .

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

AssessmentNursing Diagnosis

PlanningNursing Interventions

RationaleExpected Outcome

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

>changes in behavior (irritability)

>restless

Disturbed Sleep Pattern r/t difficulty of breathing

Short Term: After 3 hours of nursing interventions the SO will be able to verbalize understanding of sleep disturbance and identify interventions to promote sleep for the child.

-monitor vital signs -encourage SO to increase intake of warm milk for the child

- provide a quiet environment for the child

-instruct SO to provide a dim environment for the child

-to have a comparable baseline data -to promote drowsiness

-to promote comfort and relaxation /sleep periods for the child

-to promote comfort for

Short Term: After 3 hours of nursing interventions the SO shall have verbalized understanding of sleep disturbance and identified interventions to promote sleep for the

>DOB

>nasal flaring

The patient may manifest:

>lack of interest in food

>weight loss

>DOB

>tachypnea

Long Term:

After 3 days of nursing interventions, SO will be able to report improvement in sleep pattern of the child.

>advise SO to provide blanket for the child

>instruct SO to elevate HOB

the child

>to avoid chills and to promote comfort

> to maximize lung expansion of the child and to decrease DOB

child.

Long Term:

After 3 days of nursing interventions, the SO shall have reported improvement in sleep pattern for the child

5 Risk for InfectionImmuno-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 PlanningNursing Interventions

RationaleExpected Outcome

S> O>the patient manifested

>fever of 38.3ºC

>presence of adventitious sounds in both lung field.

>productive cough

>skin pale in color

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

Short term: After 6 hours of nursing interventions the patient’s S.O will verbalize her understanding of individual causative/risk factors and demonstrate lifestyle changes to prevent further infection.

Long term:

After 1-2 days

1. Monitor v/s closely, especially during initiation of therapy. 2. Instruct the S.O concerning about the disposition of secretions and report changes in color, amount and odor of secretions.

3. Encourage the SO to perform good hand washing

1. To know potential fatal complication that may occur. 2. To promote safety disposal of secretions and to assess for the resolution of pneumonia or development of secondary infection.

3. To reduce

Short term: The patient’s S.O shall have verbalized her understanding of individual causative/risk factors and demonstrate lifestyle changes to prevent further infection.

Long term:

>restlessness

The patient may manifest:

>activity intolerance

>fever

>cough and colds

>pallor

>cyanosis

>DOB

>tachypnea

>tachycardia

of nursing interventions the patient will be free from possible spread of infection.

techniques.

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 observe anything that the baby is putting in his mouth.

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

8. Ask SO to provide an adequate safe drinking milk/water for the child

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

10. Administer antimicrobials as ordered.

spread or acquisition of infection.

4. To enhance fast recovery and regain strength.

5. A good nutritional intake can strengthen body immune defense.

6. To prevent entry of microbes.

7. To eliminate MO

8. To prevent GI disturbance

9. To avoid chills and to prevent the child from having fever

10. To combat microbial pneumonias.

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

6 Risk for Imbalanced Nutrition

A disruption in the mucosal barrier causes gastric acid to come into contact 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.

AssessmentNursing Diagnosis

PlanningNursing Interventions

RationaleExpected Outcome

S= The mother verbalized an evident weight loss in her child.

O= Patient manifested:

>pallor

>lack of appetite

>lack of interest to food offered

>type of food cannot meet the metabolic demand of the child (powder milk, milo, chips)

The patient may manifest:

>constipation

>diarrhea

>weight loss

>pallor

Risk for imbalanced nutrition, less than body requirement related to decrease nutrient absorption

SHORT TERM:

After 3 hours of Nursing Interventions, the SO will 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 will be able to demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight.

-Monitor vital signs

- assess for difficulty of swallowing and the ability to swallow

- encourage family members to prepare food of patient’s preferences

- develop meal plan with the patient

- ask the SO to join the child during meal time

- To have baseline data

- can be factors that can affect ingestion and causative of altered nutrition

- to maintain adequate caloric intake

- to meet the nutritional needs of the client

- to enhance intake

SHORT TERM:

The SO shall have verbalized

understanding of causative factors when known and necessary interventions for the child.

LONG TERM:

The client shall have demonstrated behaviors, lifestyle changes to regain and/or maintain appropriate weight.