Nursing

Diagnosis I
Ineffective airway clearance r/t
bronchial inflammation AEB
abnormal breath sounds and
changes in respiration rate and
depth.
Outcome:
PS will maintain patent airway with
breath sounds clear or clearing and
decreased work of breath by end of
shift on 9/23

Evaluation: Goal met.

Nursing Diagnosis II
Activity intolerance r/t imbalance
between activity supply and demand
AEB reports of fatigue and exertional
dyspnea.
Outcome:
PS will report/demonstrate an
increase in tolerance to activity with
decreased dyspnea and vital signs
within normal range by end of shift
on 9/23

Evaluation: Goal not met.

Nursing Diagnosis III

Deficient knowledge r/t condition,
treatment, and discharge needs AEB
requests for information and
recurrence of disease.
Outcome:
PS will verbalize disease process
(using pediatric terminology) and
discharge goals, and participate in
treatment plan by end of shift
on 9/23

Evaluation: Goal partially met.

ND I Interventions
1. Auscultate lung fields/breath sounds. Determines the
presence of abnormal breath sounds (crackles, wheezing).
Fine crackles at bases may clear with deep breathing,
wheezing is a sign of airway obstruction, and requires
intervention.
2. Assess the rate and depth of respirations. Tachypnea,
shallow respirations, and asymmetric chest movement are
frequently present because of discomfort of moving chest
wall and/or fluid in lung.
3. Teach patient to perform deep breathing with coughing
exercises q1 (at least q2). Deep breathing promotes
maximum expansions of the lungs and smaller airways.
Coughing exercises help clear airways of secretions.

Objective Data
-lungs sounds diminished in
bases; expiratory wheezing
-RR 42, HR 137; abdominal
breathing
-non-productive cough with
deep breathing when using
incentive spirometer
-CXR: white areas in bases

Objective Data
-increased WOB & RR when
ambulating
-O2 saturations 90% after
ambulating to bathroom.
-PS reported feeling tired
after ambulating

ND II Interventions
1. Determine PSs response to activity. Note
reports of dyspnea, increased weakness and
fatigue, and changes in vitals during and after
activities. Established patients capabilities and
needs and facilitates choice of interventions.
2. Explain importance of rest in treatment plan
and necessity for balancing activities with rest.
Bedrest is maintained during acute phase to
decrease metabolic demands, thus conserving
energy for healing.
3. Assist with self-care activities as necessary.
Minimizes exhaustion and helps balance oxygen
supply and demand.

Objective Data
-PS asking when he will be
able to go back to school.
-PS and Mom asking what
medication will he need to
take at home.

Subjective Data
-Dad stated he was
having a hard time
breathing after soccer
-Dad stated I could see
him breathing from his
stomach

Pneumonia

Weight Data
33.1kg

ND III Interventions
1. Discuss aspects of disease and
recovery expectations. Identify self-care
needs. Information can enhance coping
and help reduce anxiety/excessive
concern. Respiratory symptoms may be
slow to resolve, and fatigue and
weakness may persist for an extended
period.
2. Reinforce importance of continu8e
deep breathing and coughing exercises.
During initial 6-8wk of discharge patient
is at greatest risk for recurrence.
3. Emphasize necessity for continuing
antibiotic therapy for prescribed period.
Early discontinuation may result in
recurrence.

Medications
- ampicillin (Omnipen) 1700mg IV, q6;
T.R. 1241.3-1655mg IV, q6
-prednisolone (Orapred) 20 mg PO solution BID;
T.R. 1.66-33.1mg BID
-albuterol (Proventil) 5mg nebulizer, q2h;
T.R. 4.97mg, every 1-4h

Concept Map Key

Developmental Data
Erikson Industry vs. Inferiority
In this developmental stage, PS is concerned with
school and social interactions. Through these
interactions children begin to develop a sense of
pride and accomplishment. PS strives to master new
tasks as seen when he was taught to use an
incentive spirometer. PS sought praise when he was
using the IS. Children who are praised and
encouraged by their parents and teachers develop a
sense of accomplishment.

Care Concept
Nursing Diagnosis/
Outcomes
Interventions
Evaluation
Assessment Data
Developmental Data
Weight Data

Sarah Brockman
NUR 4115P
6W Concept Map