Name of student: Camino, Sheena D.

Date: March 5, 2010

Patients name: V.P. Medical diagnosis: Pneumonia

Nursing Care Plan Potential Problem

ASSESSMENT Subjective: Nahihirapan siyang huminga dahl sa plema, as verbalized by the relative. Objective: - received asleep ongoing IVF infusing well @ right hand -DOB (gasping) - productive cough, sputum difficult to expectorate - good appetite, consumed all of the food served v/s: - s respiratory distress (RR: 25 CPM) - afebrile (37.2 o C) -BP: 120/80 -PR:68 DIAGNOSIS Risk for Infection r/t to Inadequate primary defenses (decreased ciliary action, stasis of secretions) RATIONALE Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatic. PLANNING Within the 8 shift, the patient will: - Verbalize understanding of individual causative/risk factors. -Identify interventions to prevent/reduce risk of infection. --Demonstrate techniques, lifestyle changes to promote safe environment. EVALUATION Goal was met. After the shift, - Monitor - Fever may be the client was temperature present because of able to infection and/or verbalize dehydration. understanding - Review importance of - These activities of individual breathing exercises, promote mobilization causative/risk effective cough, and expectoration of factors, frequent position secretions to reduce identify changes, and adequate risk of developing interventions fluid intake. pulmonary infection. to - Observe color, - Odorous, yellow, or prevent/reduce character, odor of greenish secretions risk of infection sputum. suggest the presence and of pulmonary demonstrate infection. techniques, -Demonstrate and - Prevents spread of lifestyle assist patient in fluid-borne changes to disposal of tissues and pathogens. promote safe sputum. Stress proper environment. handwashing (nurse and patient), and use gloves when handling/disposing of tissues, sputum containers. - Monitor visitors; - Reduces potential provide masks as for exposure to indicated. infectious illnesses, INTERVENTION Independent RATIONALE

Name of student: Camino, Sheena D. Date: March 5, 2010

Patients name: V.P. Medical diagnosis: Pneumonia

Nursing Care Plan Potential Problem

Likewise, conditions that cause increased production of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these mechanisms. e.g., upper respiratory infection (URI). - Reduces oxygen consumption/demand imbalance, and improves patients resistance to infection, promoting healing. - Malnutrition can affect general wellbeing and lower resistance to infection. -Reduces localized immunosuppressive effect of drug and risk of oral candidiasis.

- Encourage balance between activity and rest.

- Discuss need for adequate nutritional intake.

-Recommend rinsing mouth with water and spitting, not swallowing, or use of spacer on mouthpiece of inhaled corticosteroids. Collaborative -Obtain sputum specimen by deep coughing or suctioning for Grams stain, culture/sensitivity. - Administer

- Done to identify causative organism and susceptibility to various antimicrobials. -May be given for

Name of student: Camino, Sheena D. Date: March 5, 2010

Patients name: V.P. Medical diagnosis: Pneumonia

Nursing Care Plan Potential Problem

antimicrobials as indicated. specific organisms identified by culture and sensitivity, or be given prophylactically because of high risk.