ASSESSM ENT

INFEREN CE Subjective: Acute Pneumoni Masakit ang pain r/t a is dibdib ko as localized inflammati verbalized inflammati on by on and of the patient. persistent terminal Objective: cough airways yUse of and accessory alveoli muscle. caused yDyspnea by acute yFatigue. infection yV/S taken by as follows: various T: 37.3 agents. P: 80 Pneumoni R: 25 a Bp: 120/80 can be divided into three groups: community acquired, hospital or nursing home acquired (nosocomi al), and pneumonia in an immunoco mpr omised person. Causes include bacteria (Streptoco ccu s, Staphyloco

DIAGNO SIS

PLANNI NG
After 4 hours of nursing interventi ons , the patient will display patent airway with breath sounds clearing and absence of dyspnea

NTERVENT ION
Independent: yElevate head of the bed, change position frequently. yAssist patient with deep breathing exercises. yDemonstrat e or help patient learn to perform activity like splinting chest and effective coughing while in upright position. yForce fluids to at least 3000 ml per day and offer warm, rather than cold fluids. Collaborative : yAdminister medications as prescribe: mucolytics or expectorants. yProvide supplemental fluids.

RATION ALE
Lowers diaphragm , promoting chest expansion and expectorat ion of secretions. yDeep breathing facilitates maximum expansion of the lungs and smaller airways. yCoughin g is a natural self cleaning mechanis m. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort. yFluids especially warm liquids aid in mobilizatio n

EVALUAT ION
yAfter 4 hours of nursing intervention s, the patient was able to display patent airway with breath sounds clearing and absence of dyspnea.

ccu s, Haemophil us influenzae, Klebsiella, Legionella) . Communit y Acquired Pneumoni a (CAD) is a disease in which individuals who have not recently been hospitalize d develop an infection of the lungs. It is an acute inflammato ry condition thats result from aspiration of oropharyn geal secretions or stomach contents in the lungs.

and expectorat ion of secretions yAids in reduction of bronchosp as m and mobilizatio n of secretions. yFluids are required to replace losses and aid in mobilizatio n of secretions.