Name : Ferdy Ilham

NIM : P20620119014
Class : 2A
Task create a nursing care plan
Medic diagnostic : pneumonia
Client : Adam William
Care plan by : Ferdy Ilham
Date initiated : 22-02-2021

Assessment Nursing Diagnosis Goals and Outcomes Nursing Interventions Rationale Evaluation

Assessment :
Dyspnea (+ ) 1. Ineffective Airway Patient will maintain
Clearance patent airway with 1. Assess the rate, 1. Tachypnea, shallow Patient maintained
Cyanosis (+) breath sounds clearing; rhythm, and depth respirations and patent airway with
absence of dyspnea, of respiration, chest asymmetric chest breath sounds cleared,
Ineffective cough cyanosis, as evidenced movement, and use movement are dyspnea (-), cyanosis
by keeping a patent of accessory frequently present (-), effectively cleared
Abnormal breath airway and effectively muscles. because of secretions, normal
sounds (ronchi) clearing secretions. discomfort of respiration rate ( 20
moving chest wall breath per minute
Purulent sputum and/or fluid in lung (bpm))
due to a
respirations rate ( 26 compensatory
breath per minute response to airway
(bpm)) obstruction. Altered
breathing pattern
may occur together
 with use of
accessory muscles to
increase chest
excursion to
facilitate effective
breathing.

2. Assess cough 2. Coughing is the

effectiveness and most effective way
productivity to remove
secretions.
Pneumonia may
cause thick and
tenacious secretions
to patients.

3. Auscultate lung 3. Decreased airflow

fields, noting areas occurs in areas with
of decreased or consolidated fluid.
absent airflow and Bronchial breath
adventitious breath sounds can also
sounds: crackles, occur in these
wheezes. consolidated areas.
Crackles, rhonchi,
and wheezes are
heard on inspiration
and/or expiration in
response to fluid
accumulation, thick
secretions, and
airway spasms and
obstruction.
4. Observe the sputum 4. Changes in sputum
color, viscosity, and characteristics may
odor. Report indicate infection.
changes. Sputum that is
discolored,
tenacious, or has an
odor may increase
airway resistance
and may warrant
further intervention.

5. Assess the patient’s 5. Airway clearance is

hydration status. hindered with
inadequate hydration
and thickening of
secretions.

Therapeutic
Interventions :

1. Elevate head of 1. Doing so would

bed, change lower the
position frequently. diaphragm and
promote chest
expansion, aeration
of lung segments,
mobilization and
expectoration of
secretions.

2. Teach and assist 2.

patient with proper  Deep breathing
 deep-breathing exercises facilitates
exercises. maximum
Demonstrate proper expansion of the
splinting of chest lungs and smaller
and effective airways, and
coughing while in improves the
upright position. productivity of
Encourage him to cough.
do so often.  Coughing is a
reflex and a natural
self-cleaning
mechanism that
assists the cilia to
maintain patent
airways. It is the
most helpful way to
remove most
secretions.
 Splinting reduces
chest discomfort
and an upright
position favors
deeper and more
forceful cough
effort making it
more effective.

3. Stimulates cough
3. Suction as or mechanically
indicated: frequent clears airway in
coughing, patient who is
adventitious breath unable to do so
sounds, because of
 desaturation related ineffective cough
to airway or decreased level
secretions. of consciousness.
Note: Suctioning
can cause increased
hypoxemia; hyper
oxygenate before,
during, and after
suctioning.

4. Fluids, especially
4. Maintain adequate warm liquids, aid
hydration by in mobilization and
forcing fluids to at expectoration of
least 3000 mL/day secretions. Fluids
unless help maintain
contraindicated hydration and
(e.g., heart failure). increases ciliary
Offer warm, rather action to remove
than cold, fluids. secretions and
reduces the
viscosity of
secretions. Thinner
secretions are
easier to cough out.

5.
5. Assist and monitor  Nebulizers
effects of nebulizer humidify the
treatment and other airway to thin
respiratory secretions and
physiotherapy: facilitates
incentive liquefaction and
 spirometer, IPPB, expectoration of
percussion, postural secretions.
drainage.  Postural drainage
may not be as
Perform treatments effective in
between meals and interstitial
limit fluids when pneumonias or
appropriate. those causing
alveolar exudate or
destruction.
 Incentive
spirometry serves
to improve deep
breathing and helps
prevent atelectasis.
 Chest percussion
helps loosen and
mobilize secretions
in smaller airways
that cannot be
removed by
coughing or
suctioning.
 Coordination of
treatments and oral
intake reduces
likelihood of
vomiting with
coughing,
expectorations.

6. Helps mobilize
6. Encourage secretions and
 ambulation. reduces atelectasis.

Administer
medications as
indicated:

1.
1.  Mucolytics increase
 mucolytics or liquefy
 expectorants respiratory
 bronchodilators secretions.
 analgesics  Expectorants
increase productive
cough to clear the
airways. They
liquefy lower
respiratory tract
secretions by
reducing its
viscosity.
 Bronchodilators are
medications used to
facilitate respiration
by dilating the
airways.
 Analgesics are
given to improve
cough effort by
reducing
discomfort, but
should be used
cautiously because
they can decrease
 cough effort and
depress
respirations.

2. Increasing the
2. Use humidified humidity will
oxygen or decrease the
humidifier at viscosity of
bedside. secretions. Clean
the humidifier
before use to avoid
bacterial growth.

3. Follows progress
3. Monitor serial chest and effects and
x-rays, ABGs, extent of
pulse oximetry pneumonia.
readings. Therapeutic
regimen, and may
facilitate necessary
alterations in
therapy. Oxygen
saturation should
be maintain at 90%
or greater.
Imbalances in
PaCO2 and PaO2
may indicate
respiratory fatigue.

4.
4. Assist with  Bronchoscopy is
 bronchoscopy occasionally needed
and/or to remove mucous
thoracentesis, if plugs, drain
indicated. purulent secretions,
obtain lavage
samples for culture
and sensitivity.

 Thoracentesis is
done to drain
associated pleural
effusions and
prevent atelectasis.

5. These measures are

5. Anticipate the need needed to correct
for supplemental hypoxemia.
oxygen or Intubation is
intubation if needed for deep
patient’s condition suctioning efforts
deteriorates. and provide a
source for
augmenting
oxygenation.

6. To promote full
6. Urge all bedridden aeration and
and postoperative drainage of
patients to perform secretions.
deep breathing and
coughing exercises
frequently
 Assessment Nursing Diagnosis Goals and Outcomes Nursing Interventions Rationale Evaluation

Assessment :
Body temperature 2. hypertermia Patient maintains body 1. Monitor the 1. HR and BP Patient maintained
(390c) temperature within patient’s HR, BP, increase as body temperature
normal range. and especially the hyperthermia within normal range
flushed skin (+) tympanic or rectal progresses. (36,50C), Flushed Skin
temperature. Tympanic or rectal (-), normal heart rate
heart rate (90 bpm) temperature gives a (60 bpm), normal
more accurate respiration rate ( 20
respiration rate ( 26 indication of core breath per minute
breath per minute temperature. (bpm))
(bpm))
2. Determine the 2. Extremes of age or
patient’s age and weight increase the
weight. risk for the
inability to control
body temperature.

3. Monitor fluid 3. Fluid resuscitation

intake and urine may be required to
output. If the correct
patient is dehydration. The
unconscious, patient who is
central venous significantly
pressure or dehydrated is no
pulmonary artery longer able to
pressure should be sweat, which is
measured to necessary for
monitor fluid evaporative
status. cooling.

4. Review serum 4. Sodium losses

 electrolytes, occur with profuse
especially serum sweating and
sodium. accidental
hyperthermia.

Therapeutic
Interventions :

1. Adjust and monitor 1. Room temperature

environmental may be accustomed
factors like room to near normal
temperature and body temperature
bed linens as and blankets and
indicated. linens may be
adjusted as
indicated to
regulate
temperature of the
patient.

2. Eliminate excess 2. Exposing skin to

clothing and room air decreases
covers. warmth and
increases
evaporative
cooling.

3. Give antipyretic 3. Antipyretic

medications as medications lower
prescribed. body temperature
by blocking the
synthesis of
prostaglandins that
 act in the
hypothalamus.

4. Ready oxygen 4. Hyperthermia

therapy for extreme increases the
cases. metabolic demand
for oxygen.