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Pneumonia (Medical Management (Airway maintenance, Chest physiotherapy,…
Pneumonia
Medical Management
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High-calorie, high-protein
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Antibiotics (targeted at specific pathogen as soon as known), such as clarithromycin, azithromycin (Zithromax), doxycycline (Vibramycin)
Antiviral agents, such as oseltamivir phosphate (Tamiflu) for viral pneumonia; ribavirin (Virazole)
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Bronchodilators, such as albuterol sulfate
Analgesics and antipyretics, such as acetaminophen (Tylenol)
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Incidence
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With viral pneumonia, men appear to be affected more commonly than women.
Mycoplasma pneumonia is believed to be the most common cause of pneumonia in young adults and occurs most commonly in males.
Community-acquired pneumonia is very common in adults over age 65 and usually results from the influenza virus.
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Nursing Diagnosis #1 Ineffective airway clearance r/t tracheal bronchial inflammation, increased sputum production AEB changes in rate, depth of respirations.
Goal: patient display patent airway with breath sounds clearing, absence of dyspnea, and cyanosis.
Nursing intervention #1: Assess the rate and depth of respirations and chest movement. R: Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung.
Nursing intervention #2: Elevate head of bed, change position frequently. R: Doing so would lower the diaphragm and promote chest expansion,
Nursing intervention #3 Suction as indicated: frequent coughing, adventitious breath sounds, desaturation related to airway secretions. R: Stimulates cough or mechanically clears airway
Nursing intervention #4 Administer medications as indicated: mucolytics, expectorants, bronchodilators, analgesics. R: Aids in reduction of bronchospasm and mobilization of secretions.
Nursing intervention #5 Force fluids to at least 3000 mL/day. Offer warm, rather than cold, fluids. R: Fluids, especially warm liquids, aid in mobilization
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Nursing Diagnosis #2 Ineffective breathing pattern related to presence of tracheo-bronchial secretions and nasal secretions AEB by dyspnea and nasal flaring
Goal: The patient will verbalize increased ease of respiration, by end of shift.
Nursing Intervention #1: Assess and record respiratory rate and depth at least every 4 hours.It is important to take action when there is an alteration in the pattern of breathing to detect early signs of respiratory compromise.
Nursing Intervention #2: Assess ABG levels, according to facility policy.This monitors oxygenation and ventilation status.
Nursing Intervention #3: Place patient with proper body alignment for maximum breathing pattern,as needed. A sitting position permits maximum lung excursion and chest expansion.
Nursing Intervention #4:Maintain a clear airway by encouraging patient to mobilize own secretions with successful coughing, as needed. This facilitates adequate clearance of secretions.
Nursing Intervention #5:Suction secretions, as necessary.This is to clear blockage in airway.
Evaluation: The patient will verbalized increased ease of respiration, by end of shift.
Nursing Diagnosis #3 Risk for Deficient Fluid Volume R/T Excessive fluid loss (fever, profuse diaphoresis, mouth breathing/hyperventilation, vomiting)
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