Cough (both productive and non productive) nasal output, shortness of breath, tachipnea, breath sounds are limited, retraction, fever, diaporesis, ronchii, cyanosis, leukocytosis.
Children will experience effective breathing pattern characterized by:
- Voice lung breath clean and the same on both sides
- The body temperature within the limits of 36.5 to 37.2 OC
- The rate of breathing within the normal range
- There is no coughing, cyanosis, nasal output, retraction and diaporesis
Perform assessments every 4 hours of respiration rate, temperature, and the signs of the effectiveness of the airway.
R /: Evaluation and reassessment of the actions that will be / have been granted.
Perform chest physiotherapy is scheduled
R /: Removing the secretion of the airway, preventing obstruction
Give Oxygen moist, review the effectiveness of therapy
R /: Increased lung tissue oxygen supply
Give antibiotics and antipyretic, review the effectiveness and side effects (rash, diarrhea)
R /: Eradication of germs as factors causing interference.
Make a check photo thoracic
R /: Evaluation of the effectiveness of the circulation of oxygen, evaluating the condition of lung tissue
Perform suction gradually
R: Helping cleaning airway
Record the results of pulse oximeter when installed, every 2-4 hours
R: Evaluate periodically the success of therapy / health team action.
Nursing Diagnosis for Pneumonia: Ineffective Breathing Pattern