Nursing Diagnosis : Ineffective Breathing Pattern
Ineffective breathing pattern related to lung infection
Characteristics:
Cough (either productive or non productive) nasal output, shortness of breath, tachipnea, limited breath sounds, retractions, fever, diaporesis, ronchii, cyanosis, leukocytosis.
Goals:
Children will experience an effective breathing pattern characterized by:
- Lung breath sounds clear and equal on both sides
- Body temperature in the range 36.5 to 37.2 OC
- Breathing rate in normal range
- There is no cough, cyanosis, nasal output, retraction and diaporesis
Nursing Interventions – Ineffective breathing pattern related to Pneumonia:
1. Do the assessment every 4 hours for respiration, temperature, and signs of the effectiveness of the airway.
R: Evaluation and reassessment of the actions that will be / have been given.
2. Perform chest Phisioterapi in scheduled
R: Removing the secretion of the airway, preventing obstruction
3. Give Oxygen moist, review the effectiveness of therapy
R: Increased lung tissue oxygen supply
4. Give antibiotics and antipyretics according to order, review the effectiveness and side effects (rash, diarrhea)
R: Eradication of bacteria as a factor of disturbance causa
5. Check the photo thoracic
R: Evaluation of the effectiveness of the circulation of oxygen, the evaluation of lung tissue
6. Perform suction gradually
R: Helping the airway clearance
7. Record the results of pulse oximeter when installed, every 2-4 hours
R: Periodic evaluation of therapeutic efficacy / health team action.
