Nursing Care Plan

Assessment Nursing Diagnosis Inference Planning Nursing Intervention Rationale Evaluation

Subjective: Impaired gas Pneumonia is an After 4 hours of Independent: Manifestation of respiratory
After 4 hours of
“bago siya exchange related to excess of fluid in the nursing Assess respiratory distress is dependent on indicative
nursing interventions,
iconfine, collection of lungs resulting from interventions, rate, depth and of the degree of lung involvement
the patient will
nahihirapan secretions affecting an inflammatory the patient will ease. and underlying general status achieve timely
siyang oxygen exchange process. The achieve timely resolution of current
huminga at across alveolar inflammation is resolution of Monitor body High fever greatly increases infection without
ubo ng ubo, triggered by many current infection temperature. metabolic oxygen consumption complications
membrane.
para bang may infectious organisms without and alters cellular oxygenation
naka bara sa and by inhalation of complications, Elevate head of the
lalamunan at irritating agents. bed and change Promotes expectoration clearing or
hindi niya Infectious pneumonias position frequently infection. Reduces likelihood of
alam ilabas.” are categorized as Limit visitors as exposure to other infectious
-guardian community acquired indicated pathogens.
(CAP) or hospital
Objective: acquired (nosocomial) Institute isolation Isolation technique may be desired
Deep depending on where precaution. to prevent spread and protect
breathing the patient was patient from other infectious
Vital Signs; exposed to infectious Suction as process
Temp: 36.2 agent. indicated.
RR: 38 Stimulates cough or mechanically
PR:98 Assist with clears airway in patient who is
O2Sat: 93% nebulizer unable to cough effectively.
BP: 80/60 treatments.
Facilitates liquefaction and
Monitor removal of secretions
effectiveness of
antimicrobial Signs of improvement in condition
therapy. should occur within 24- 48 hrs.

Collaborative: These drugs are used to combat

Administer most of the microbial pneumonias.
antimicrobials as You sent
prescribed,
Jehan Lois S. Quines
DRUG STUDY OF FLUIMUCIL

Name of Drugs Dosage/ Mechanism of Action Indication Contraindication Adverse Effect Nursing responsibilities
Frequency/
Timing/
Route
Generic Name: Below 12 The mucolytic effect of Acute & chronic Known Significant: Maintaining Patent Airway
N- years: 5-10 acetylcysteine (Fluimicil) resp tract hypersensitivity to The most frequent adverse Clearance by Assessing the rate,
acetylcysteine ml of is linked to the sulfhydryl infections w/ acetylcysteine or to events associated with the rhythm, and depth of respiration,
10/20% group in the molecule. abundant mucus any of the excipients. oral administration of chest movement, and use of
Brand Name: solution by This group is likely to secretions due to Acetylcysteine acetylcysteine are accessory muscles
Fluimucil nebulizer open disulphide bonds in acute bronchitis, (Fluimucil) granules gastrointestinal in nature.
every 6-8 hr the mucosa, reducing chronic and tablets are Hypersensitivity reactions Monitoring cough effectiveness
Classification: PRN. viscosity. bronchitis & its contraindicated in including anaphylactic and productivity
Mucolytics exacerbations, patients suffering shock,
Acetylcysteine (Fluimucil) pulmonary from anaphylactic/anaphylactoi Auscultate lung fields, noting areas
Restores hepatic emphysema, phenylketonuria due d reaction, bronchospasm, of decreased or absent airflow and
glutathione levels by mucoviscidosis to the aspartame angioedema, rash and adventitious breath sounds:
producing the glutathione & bronchiectasis. content. pruritus have been crackles, wheezes. And observe the
precursor L-cysteine. To clear phlegm Children below 2 reported less frequently. sputum color, viscosity, and odor.
Glutathione must and strengthen years of age. Having headache, nausea, Report changes.
inactivate an intermediate lung functions. vomiting, tachycardia,
metabolite (N-acetyl-p- Assess the patient’s hydration
benzoquinoneimine) of status and proper hygiene.
paracetamol, which is
believed to be hepatotoxic.
In the case of
acetaminophen overdose,
excessive levels of this
metabolite are formed
because the primary
metabolic pathways
(glucuronide and sulfate
conjugation) are saturated.