PNEUMONIA

NAME : RAHMA ARIFAH PUTRI

NIM : 21117095

LETCURE : YUDI ABDUL MAJID,S.Kep.,Ns.,M.Kep

 Case
Mr. A 67 year old is admitted to hospital with
complaints of severe shortness of breath since 2
days before being admitted to hospital,
coughing up phlegm, thick, and a lot. Client
complains of increased shortness when
walking/activity. Clients appear weak and
installed cannula nasal oxygen 2 liters per
minute. The client himself is a smoker since he
was a teenager.
 Assessment

• Physical examination
Breath frequency : 30 times per minute
Pulse : 92 times per minute
Blooad pressure : 160/90 mmHg
 Diagnosis
• Nursing Diagnosis
1. The ineffectiveness of airway cleaning
associated with sputum buildup
2. Disorders of gas exchange associated with
inflammatory effects
3. Activity intolerance associated with dyspnea
 Intervension
• The ineffectiveness of airway cleaning
associated with sputum buildup
Intervention Rational

Airway management Facilitating the patency of the airway

Asthma management Identify, handle, and prevent

Respiratory monitoring
inflammatory/constricting reactions in
the airway
Collect and analyze patient data to
ensure patency of the airway and
adequate gas exchange
• Disorders of gas exchange associated with
inflammatory effects
intervention Rational

Acid-base management Improves acid-base balance and

prevents complications due to
higher/lower than expected serum
pCO2 levels
Oxygen therapy Give oxygen and monitor its
effectiveness

Monitoring vital signs Cardiovascular, respiratory, and body

temperature data to determine and
prevent complications
• Activity intolerance associated with dyspnea

intervention Rational

Energy management Regulate energy use to overcome or

prevent fatigue and optimize
function
 Implementation
The ineffectiveness Nursing activity :
of airway cleaning - Review and documen
associated with • Effectiveness of prescription drugs
sputum buildup • Trends in arterial blood gaas frequency, depth, and effort of
breathing
• Types of sputum
- Auscultation of the anterior and posterior chest to detect
additional breath sounds
Extension for patients / families :
- Explain the use of supporting equipment such as inhalers
correctly
- Inform patients and families about the smoking ban in the
treatment room
- Instruct patients about coughing and breathing techniques
to facilitate secretions
- Teach clients and families about the meaning of changes in
sputum
Collaborative activity
- Tell the doctor about abnormal blood gas results
- Do or help in therapy such as an ultrasonic nebulizer in
accordance with institutional policies and protocols
Disorders of gas Nursing activities :
exchange associated - Kaji
with inflammatory • Breath frequency
effects • Breath production
- Monitor blood gas results
- Monitor O2 saturation with a pulse oximeter
Extension for patients/families :
- Explain the use of tools needed and the reasons for
their use such as oxygen
- Teach patients breathing and relaxation techniques
- Inform patients and families that smoking is
prohibited
Collaborative activity :
- Give prescribed medication
- Report if there are changes to the related
assessment data such as analysis of gas from
arteries and sputum
- Give oxygen, bronchodilators, or ultrasonic
nebulation if needed
Activity intolerance Nursing activities :
associated with dyspnea - Monitor the cardiorespiratory response to activities
such as dyspnea, tachycardia and respiratory
frequency
- Monitor the client’s oxygen response to self-care
activities or nursing activities such as pulse, and
respiratory frequency
Extension for patients/families :
- Use of controlled breathing techniques during activity
- Recognize signs and symptoms of intolerance to
activities and other related conditions that need to be
reported to the doctor
- Teach about managing time management activities
and techniques
Other activities :
- Monitor vital signs before, during, and after the
activity
- Stop activities if vital signs are not in the normal
range or activities cannot be tolerated such as
dyspnea
 Evaluation
1. Observe the client’s breathing frequency,
pulse and blood pressure
2. Observation of ABGs test results, pulse
oximetry, CBC, and chest x-ray
3. Client response when on the move
4. Client’s plan to stop smoking possible
complications