NURSING CARE PLAN

Definition
Bronchopneumonia or bronchial pneumonia is the acute inflammation of the walls of the bronchioles. It is a type of
pneumonia characterized by multiple foci of isolated, acute consolidation, affecting one or more pulmonary lobules.
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.

Statistics
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 ARIs 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.

Nursing Care Plans

Ineffective Airway Clearance
NDx: Ineffective airway clearance r/t accumulation of tracheobronchial secretions
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

Planning

Nursing
Interventions

Rationale

SHORT TERM:After 3-4 hours

Restlessne
1.
Monitor and 1.
To obtain
of NI, pt.s SO will be able to
ss with nasal
record vital
baseline data
demonstrate improve airway
flaring
signs
2.
To know the
clearance AEB reduction of
With rales
Assess
patients general
congestion with breath sounds 2.
on both lung
patients
condition
clear
and
RR
improveLONG
fields
condition.
TERM:
3.
To promote
warm,
3.
Elevate head
maximal

Expected Outcome
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 improve

flushed skin

After 2-3 days of NI, pt. will be

able to establish and maintain

minimal
airway patency.
colorless nasal
secretions

tachypnea
AEB
RR=53bpm

DOB

tachycardia

irritability

chest
indrawing

cough

cyanosis

noisy
breathing
pallor

LONG TERM:
inspiration,
enhance
After 2-3 days of NI, pt.
expectoration of
secretions in order shall have established and
maintained airway patency.
to improve
ventilation

of bed and
encourage
frequent position
changes.
4.

5.

Keep back
dry and loosen
clothing

4.

Auscultate
breath sounds
and assess air
movement

To promote
comfort and
adequate
ventilation

5.

To ascertain
status and to note
progress

6.

Monitor child
for feeding
intolerance and 6.
To avoid
abdominal
compromising the
distention
airway

7.

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

7.

To help liquefy
the secretions

8.

Rest will
prevent fatigue
and decrease

8.

9.

changes in
RR and rhythm

risk for
infection

orthopnea

tachypnea

10.

Instruct the
SO to provide
adequate
rest periods for
the child
9.

oxygen demands
for metabolic
demands
To further
mobilize
secretions

Give
expectorants
and
10.
To clear airway
bronchodilators
when secretions
as ordered.
are blocking the
airway
11.
Administer
oxygen therapy 11.
indicated to
and other
increase oxygen
medications as
saturation.
ordered.

Impaired Gas Exchange

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

The 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.
Assessment
Restlessne

ss

Planning
SHORT TERM:After 6
hours of NI, pt will be

Nursing Interventions Rationale

1.

able to demonstrate

with nasal improvement in gas

flaring
exchange AEB a

2.

With rales decrease in respiratory

on both lung rate to normalLONG
fields
TERM:
Metabolic After 1-2 days of NI, pt
will be able to
acidosis

Observe color 2.
Cyanosis of nail
of skin, mucous
beds may
membranes and
represent
nail beds, noting
vasoconstriction or
presence of
the bodys
peripheral
response to fever/
cyanosis.
chills

Elevate head 3.
To promote
of bed and
maximal
Circumencourage
inspiration,
oral cyanosis
improved ventilation and
frequent position
enhance
adequate oxygenation of
DOB
changes.
expectoration of
tissues AEB absence of
secretions in order
tachypnea
4.
Keep back
to improve
symptoms of respiratory
dry.
ventilation
distress.
demonstrate

3.

Monitor and 1.
To obtain
record vital signs
baseline data

Expected Outcome
SHORT TERM:Patient shall
demonstrate improvement in gas
exchange AEB a decrease in
respiratory rate to normalLONG
TERM:Patient shall demonstrate
improved ventilation and
adequate oxygenation of tissues
AEB absence of symptoms
of respiratory distress.

5.
6.

Promote

adequate rest
periods
5.

7.

Change
position q 2 hrs.

8.

Keep
environment
allergen free

9.

10.

11.

4.

Suction
secretions PRN

To avoid
coughing
Rest will prevent
fatigue and
decrease oxygen
demands for
metabolic demands

6.

To promote
drainage of
secretions

7.

To reduce
irritant effects on
airways

Instruct SO to
increase fluid
intake of the child 8.
Administer
oxygen therapy
as ordered.
9.

To clear airway
when secretions
are blocking the
airway
indicated to
increase oxygen
saturation

10.

To liquefy
secretions

11.

O2 therapy is
indicated to
increase oxygen
saturation

Hyperthermia
A 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. Interleukin-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.
Assessment

Planning

Short-term:After 3 hours of
Increase
nursing interventions the pts
body temp.
at 37.9C temperature will be decrease
Skin is

to normal limits from 37.9 to

Nursing Interventions Rationale

1.

Assess pts
condition and
monitored vital
signs.

1.

2.

To have
baseline data.
To promote
heat loss by

Expected Outcome
Short-term:After 3 hours of
nursing interventions the pts
temperature shall have
decreased to normal limits from

2.

Perform tepid
sponge bath

3.

Instruct the SO
3.
To support
to provide an
circulating
increase fluid
volume and
intake for the
tissue perfusion.
child.

warm to
touch.

evaporation and
conduction.

4.
To promote
Maintain
pts safety and
37.5CLong-term:
patent airway and
to avoid chills.
After 3 days of nursing
provide blanket for
interventions the pt will be able
the child.
5.
To reduce
Increase to maintain a temp. within
metabolic
5.
Maintain bed
in RR
demands/
normal range .
rest and adequate
Oxygen
chills
rest periods.
consumption.
lack of
6.
Ask SO to
6.
To meet
appetite
provide high
increase
caloric diet for the
metabolic
child
demands.
With
flushed
skin.

4.

7.

Administer
antipyretics as
ordered.

7.

To lower the
temperature.

37.9 to 37.5CLong-term:
After 3 days of nursing
interventions the pt shall be
able to maintain a temp. within
normal range .

Disturbed Sleeping Pattern

NDx: Disturbed Sleep Pattern r/t difficulty of breathing
Sleep is disrupted when a person experiences unpleasant sensation arising from difficulty of breathing and ineffective
expectoration of mucus secretions in the airways.
Assessment

Short Term:After 3 hours of

changes
nursing interventions the SO
in behavior
(irritability) will be able to verbalize

restless

DOB

nasal
flaring

Planning

understanding of sleep

Nursing Interventions Rationale

1.

2.

disturbance and identify

interventions to promote sleep
for the child.Long Term:
After 3 days of nursing

3.

interventions, SO will be able to

The
report improvement in sleep
patient may pattern of the child.
manifest:
lack of
interest in

4.

Monitor vital
signs

1.

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
Advise SO to

2.

3.

To have a
comparable
baseline
data-to
promote
drowsiness
To
promote
comfort and
relaxation
/sleep
periods for
the child
To

Expected Outcome
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 child.Long Term:
After 3 days of nursing
interventions, the SO shall have
reported improvement in sleep
pattern for the child

promote
comfort for
the child
food

DOB

tachypne
a

To avoid
chills and to
promote
comfort

5.

To
maximize
lung
expansion of
the child and
to decrease
DOB

provide blanket for

the child

weight
loss

4.

5.

Instruct SO to
elevate HOB

Risk for Infection

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

Immuno-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

ever of
38.3C

Planning
Short term: After 6 hours of
nursing interventions the

Nursing Interventions Rationale

1.

patients S.O will verbalize

presence of her understanding of

adventitious
individual causative/risk
sounds in both
factors and demonstrate
lung field.
lifestyle changes to prevent
productive further infection.Long term:
cough
After 1-2 days of nursing

2.

Expected Outcome

Short term: The patients

Monitor v/s
1.
To know
S.O shall have verbalized
closely, especially
potential fatal
during initiation of
complication that her understanding of
individual causative/risk
therapy.
may occur.

Instruct the S.O 2.

To promote
concerning about
safety disposal of
the disposition of
secretions and to
secretions and
assess for the
report changes in
resolution of
color, amount and
pneumonia or
skin pale in interventions the patient will
odor of secretions.
development of
color
be free from possible spread
secondary
of infection.
3.
Encourage the
restlessnes
infection.
SO
to
perform
s
good hand washing 3.
To reduce
activity
techniques.
spread or
intolerance
acquisition of
4.
Encourage

factors and demonstrate

lifestyle changes to
prevent further
infection.Long term:
The patient shall have
been free from possible
spread of infection.

fever
cough and
colds

pallor

cyanosis

DOB

tachypnea

tachycardia

adequate rest.
5.

Stress the
importance of
increasing the
childs nutritional
intake.

infection.
4.

To enhance
fast recovery and
regain strength.

5.

A good
nutritional intake
can strengthen
body immune
defense.

6.

Encourage the
mother to keep an
eye to the baby and
observe anything
6.
6. To prevent
that the baby is
entry of microbes.
putting in his
mouth.
7.
To eliminate
MO
7.
Ask SO to
provide a good
8.
To prevent GI
hygiene for the
disturbance
child. (bed bath)
8.

Ask SO to
provide an
adequate safe
drinking milk/water

9.

To avoid chills
and to prevent the
child from having
fever

for the child

9.

Ask SO to keep
the child warm and 10.
To combat
to provide blanket
microbial
pneumonias.
10.
Administer
antimicrobials as
ordered.

Risk for Imbalanced Nutrition

NDx: Risk for imbalanced nutrition, less than body requirement related to decrease nutrient absorption
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.
Assessment

pallor

Planning
SHORT TERM:After 3 hours of
Nursing Interventions, the SO
will be able to verbalize

Nursing Interventions

Rationale

1.

1.

Monitor vital
signs

Expected Outcome

SHORT TERM:The SO
To have
shall have verbalized
baseline
understanding of

lack of appetite

understanding of causative

Assess for
data
factors when known and
difficulty of
lack of interest necessary interventions for the
Can be
swallowing and the 2.
to food offered
factors that
child.LONG TERM:
ability to swallow
can affect
After 2 days of Nursing
type of food
3.
Encourage
ingestion
Interventions, the patient will
cannot meet the
family members to
and
metabolic demand be able to demonstrate
prepare food of
causative of
of the child
behaviors, lifestyle changes to
patients
altered
(powder milk, milo,
regain and/or maintain
preferencesnutrition
chips)
develop meal plan
appropriate weight.
3.
To
with the patient
constipation
maintain
4.
Ask the mother
adequate
diarrhea
to join the child
caloric
weight loss
during meal time
intake
pallor

2.

4.

To meet
the
nutritional
needs of the
client

5.

To
enhance

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.

intake