NURSING CARE PROCESS

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION

Objective cues: Infection related Pneumonia is caused After 4 hours of  Elicited the baby’s  Classic signs of The client experienced
to invasion of by a bacterial or viral nursing description of illness, pneumonia improvement in infection
>Hyperthermic – viral organism infection that results in intervention, including onset, include chills, as evidenced by:
38.3 degree an inflammatory client will chills and cough. fever, cough, and  Normothermia –
Celcius process in the lungs. experience dyspnea. 36.8 degree
improvement in (Nursing Care Celsius
>Elevated white infection. Plan, 6th edition,  Normal WBC
blood cell count (Nursing Care Plan, Gulanick/Myers count - 10.78x
– 13.78 x 109/L 6th edition, pg. 478) 109/L
Gulanick/Myers pg.  Assessed
>Tachycardic – 477) immunization status.  Preventive
190 beats per measures with
minute pneumococcal
vaccine should
>Chills be assessed.
(Nursing Care
Plan, 6th edition,
Gulanick/Myers
pg. 478)
 Assessed vital signs,
closely monitoring  Continued fever
temperature may be caused
fluctuations. by drug allergy,
drug – resistant
bacteria,
superinfection or
inadequate lung
drainage.
(Nursing Care
Plan, 6th edition,
Gulanick/Myers
 Auscultated lung pg. 478)
sounds.
 Bronchial breath
sounds are
evident in areas
of lung
consolidation.
Crackles are
evident if fluid is
 present in
interstitial or
alveolar lung
areas. (Nursing
Care Plan, 6th
edition,
Gulanick/Myers
 Monitored WBC pg. 478)
count.
 Rising WNC
count indicates
the body’s efforts
to fight
pathogens.
(Nursing Care
Plan, 6th edition,
Gulanick/Myers
 Assessed for signs pg. 478)
of dehydration.
 Water loss is
increased with
fever. (Nursing
 Care Plan, 6th
edition,
Gulanick/Myers
pg. 478)
 Monitored chest x –
ray reports.
 Pneumonia
causes increased
areas of density
on chest
radiograph,
occurring in an
isolated segment,
a lobe,
unilaterally or
bilaterally.
(Nursing Care
Plan, 6th edition,
 Continued to monitor Gulanick/Myers
the effectiveness of pg. 478)
the prescribed
antibiotic agents.  Parenteral
 intravenous
antibiotics are
usually given for
the first few days
of acute cases
and then
changed to oral
antibiotics, which
may be adequate
for milder cases
from the first day.
(Nursing Care
 Used appropriate Plan, 6th edition,
therapy for elevated Gulanick/Myers
temperature; pg. 478)
antipyretics, tepid
sponge bath.  This maintains
normothermia
and reduces
metabolic needs.
(Nursing Care
 Administered Plan, 6th edition,
prescribed antibiotic Gulanick/Myers
agent: pg. 479)
- Ceftazidime 300ml
q80  This is an
indicator or
benchmark used
to measure
quality of care in
hospitals.
(Nursing Care
Plan, 6th edition,
Gulanick/Myers
pg. 479)