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2. Prevent complications.
3. Support recuperative process.
4. Provide information about disease process, prognosis and treatment.
Discharge Goals
1. Ventilation and oxygenation adequate for individual needs.
2. Complications prevented/minimized.
3. Disease process/prognosis and therapeutic regimen understood.
4. Lifestyle changes identified/initiated to prevent recurrence.
5. Plan in place to meet needs after discharge.
Diagnostic Studies
Chest x-ray: Identifies structural distribution (e.g., lobar, bronchial); may also reveal
multiple abscesses/infiltrates, empyema (staphylococcus); scattered or localized infiltration
(bacterial); or diffuse/extensive nodular infiltrates (more often viral). In mycoplasmal
pneumonia, chest x-ray may be clear.
CBC: Leukocytosis usually present, although a low white blood cell (WBC) count may be
present in viral infection, immunosuppressed conditions such as AIDS, and overwhelming
bacterial pneumonia. Erythrocyte sedimentation rate (ESR) is elevated.
May be related to
Pleuritic pain
Possibly evidenced by
Dyspnea, cyanosis
Desired Outcomes
Display patent airway with breath sounds clearing; absence of dyspnea, cyanosis.
Nursing Interventions
Rationale
Tachypnea, shallow respirations, and
Nursing Interventions
Rationale
Crackles, rhonchi, and wheezes are heard
on inspiration and/or expiration in
wheezes.
frequently.
Teach and assist patient with proper deepbreathing exercises. Demonstrate proper
splinting of chest and effective coughing
while in upright position. Encourage him to
do so often.
when appropriate.
Nursing Interventions
Rationale
Aids in reduction of bronchospasm and
oximetry readings.
May be related to
Possibly evidenced by
Dyspnea, cyanosis
Tachycardia
Restlessness/changes in mentation
Hypoxia
Desired Outcomes
Nursing Interventions
Rationale
Manifestations of respiratory distress are
oxygenation.
activities.
infection.
Nursing Interventions
Rationale
effective coughing.
improve ventilation.
Anxiety is a manifestation of psychological
concerns and physiological responses to
intervention.
Follows progress of disease process and
Desired Outcomes
Nursing Interventions
Rationale
Elevated temperature and prolonged fever
hypotension, tachycardia.
membranes.
vomiting.
intake.
Weigh as indicated.
4. Imbalanced Nutrition
Nursing Diagnosis
Anorexia associated with bacterial toxins, the odor and taste of sputum, and certain aerosol
treatments
Desired Outcomes
Nursing Interventions
Identify factors that are contributing to
nausea or vomiting: copious sputum,
aerosol treatments, severe dyspnea, pain.
Rationale
reduce nausea.
hr before meals.
these treatments.
feedings.
Nursing Interventions
Rationale
intervals.
Bowel sounds may be diminished if the
infectious process is severe. Abdominal
abdominal distension.
5. Acute Pain
Nursing Diagnosis
Acute Pain
May be related to
Persistent coughing
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Rationale
Chest pain, usually present to some
degree with pneumonia, may also herald
the onset of complications of pneumonia,
such as pericarditis and endocarditis.
Changes in heart rate or BP may indicate
breathing exercises.
indicated.
6. Activity Intolerance
Nursing Diagnosis
Activity intolerance
May be related to
General weakness
Possibly evidenced by
Development/worsening of pallor/cyanosis
Desired Outcomes
Nursing Interventions
Rationale
promoting rest
Nursing Interventions
Rationale
Desired Outcomes
Nursing Interventions
Rationale
During this period of time, potentially fatal
complications (hypotension, shock) may
develop.
Although patient may find expectoration
handwashing technique.
acquisition of infection.
Nursing Interventions
Rationale
infection.
therapy.
8. Deficient Knowledge
Nursing Diagnosis
May be related to
Lack of exposure
Misinterpretation of information
Altered recall
Possibly evidenced by
Failure to improve/recurrence
Desired Outcomes
Nursing Interventions
Rationale
Promotes understanding of current
situation and importance of cooperating
with treatment regimen.
Information can enhance coping and help
reduce anxiety and excessive concern.
homemaker needs.
exercises.
pneumonia.
Early discontinuation of antibiotics may
Nursing Interventions
Rationale
Smoking destroys tracheobronchial ciliary
URIs.
Stress importance of continuing medical
follow-up and obtaining vaccinations as
appropriate.
Impaired dentitionmay be related to dietary habits, poor oral hygiene, chronic vomiting,
possibly evidenced by erosion of tooth enamel, multiple caries, abraded teeth.