Question

Pneumonia Nursing Diagnosis Nursing Diagnosis Positive Outcomes Positive Outcomes Negative Outcomes Negative Outcomes Evaluation Evaluation

Answer 1

PNEUMONIA:

Nursing diagnosis: 1

Ineffective airway clearance related to obstructions in the respiratory tract to maintain a clear airway.

Interventions:

• Assess the rate, mood, and profundity of breath, chest development, and utilization of frill muscles.
• Assess hack viability and profitability
• Auscultate lung fields, taking note of territories of diminished or missing wind stream and extrinsic breath sounds: snaps, wheezes.
• Observe the sputum shading, thickness, and smell. Report changes.
• Assess the patient's hydration status.
• Elevate head of bed, change position much of the time.
• Teach and help quiet with legitimate profound breathing activities. Show legitimate supporting of chest and powerful hacking while in upstanding position. Urge him to do so frequently.
• Suction as showed: visit hacking, extrinsic breath sounds, desaturation identified with aviation route discharges.
• Maintain sufficient hydration by driving liquids to at any rate 3000 mL/day except if contraindicated (e.g., cardiovascular breakdown). Offer warm, as opposed to cold, liquids.
• Assist and screen impacts of nebulizer treatment and other respiratory physiotherapy: impetus spirometer, IPPB, percussion, postural waste.
• Perform medications among suppers and breaking point liquids when proper.
• Encourage ambulation.
• Administer prescriptions as demonstrated:

• mucolytics
• expectorants
• bronchodilators
• analgesics

• Use humidified oxygen or humidifier at bedside.
• Monitor sequential chest x-beams, ABGs, beat oximetry readings.
• Assist with bronchoscopy or potentially thoracentesis, whenever demonstrated.
• Anticipate the requirement for supplemental oxygen or intubation if patient's condition disintegrates.
• Urge all laid up and postoperative patients to perform profound breathing and hacking practices every now and again.

Positive outcomes:

The following are the regular expected results for insufficient aviation route freedom auxiliary to pneumonia:

• Patient will recognize/exhibit practices to accomplish aviation route freedom.
• Patient will show/keep up patent aviation route with breath sounds clearing; nonattendance of dyspnea, cyanosis, as confirm by keeping a patent aviation route and successfully clearing discharges.

Negative outcomes:

Airway clearance will get worst due to improper caring as negative outcome.

Evaluation:

The patient airway will get cleared with the above interventions.

Nursing diagnosis: 2

Impaired or excess gas exchange due to less oxygen or carbon dioxide elimination at alveolar capillary membrane.

Interventions:

• Assess breaths: note quality, rate, beat, profundity, utilization of adornment muscles, straightforwardness, and position expected for simple relaxing.
• Observe shade of skin, mucous films, and nail beds, taking note of quality of fringe cyanosis (nail beds) or focal cyanosis (circumoral).
• Assess mental status, anxiety, and changes in level of cognizance.
• Assess uneasiness level and empower verbalization of sentiments and concerns.
• Monitor pulse and cadence and circulatory strain.
• Monitor body temperature, as demonstrated. Help with solace measures to decrease fever and chills: expansion or evacuation of bedcovers, agreeable room temperature, lukewarm or cool water wipe shower.
• Observe for disintegration in condition, noticing hypotension, plentiful measures of ridiculous sputum, paleness, cyanosis, change in LOC, extreme dyspnea, and fretfulness.
• Monitor ABGs, beat oximetry.
• Maintain bedrest by arranging movement and rest periods to limit vitality use. Empower utilization of unwinding methods and diversional exercises.
• Elevate head and empower successive position changes, profound breathing, and compelling hacking.
• Administer oxygen treatment by fitting methods: nasal prongs, veil, Venturi cover.

Positive outcomes:

Regular expected results for the nursing analysis hindered gas trade optional to pneumonia:

• Patient will show improved ventilation and oxygenation of tissues by ABGs inside patient's satisfactory range and nonappearance of manifestations of respiratory trouble.
• Patient will keep up ideal gas trade.
• Patient will take part in activities to boost oxygenation.

Negative outcomes:

Patient’s ventilation may not be improved due improper ABG exchange.

Evaluation:

Gas exchange will get improved