BRONCHOPNEUMONIAN NURSING CARE

Assessment
Collecting Data
a. Identity Kx : Include the name of the client , age , type of sex ,
religion, education , employment .
b. Complaints primary : In general, the temperature of the agency clients high (39-
40 0 C), the breathing that fast or claustrophobic and sometimes accompanied by seizures .
c. Medical history :
a. History of disease right
now : Initially cough dry then become productive , raised the
heat that suddenly high sometimes accompanied by pain chest. In this condition
the client will be agitated .
b. History of
disease dahul u: Decrease power resistant body or disease that never suffered chiefly a
disease that is common in the family , habits of life , and patterns
of eating the less healthy .
c. History of the disease the family : The presence of a disease that
is common in the family , habits of life and patterns of eating the less healthy .
Health function patterns :
a. Patterns of
nutrition and metabolism : In eating and drinking at Px tends to decline , due
to tightness and coughing .
b. Pattern of elimination : Changes in the pattern
of elimination , experiencing constipation ( sometimes ).
c. Patterns rest and sleep : Kx experiencing disturbances in sleep due
to coughing and shortness who suffered / experienced Px .
d. Pattern of activity and training : Kx can not move because
of tightness and coughing .
e. Patterns peersepsi and the concept of self : Px worried with the
situation because it does not know what that is going to happen and what that will do .
f. Patterns SENSARI and cognitive : At Px pneumonia usually do
not experience the disorder .
g. The pattern of reproduction social : Px types
of sex male / female , whether there are defects in the system of reproduction .
 h. Pattern of role relationships : Are experiencing interference in carr
ying out their daily roles .
i. Pattern combating stes s: There is a feeling
of stress for Disease who suffered so that the support of family is very meaningful to cope
with stress.
j. The pattern of governance values and kepercayaa n: In the
pattern is there who entrust themselves to the things that are unseen .
Physical examination
a. General circumstances : Kx is weak , high temperature (39 -
40 0 C). Breathing fast and shallow ( shortness of breath ), cough , presence
of cyanosis . Can also patients experiencing kegelisah due to disease that suffered .
b. Skin , hair , nails : Turgor decreased skin , normal hair , nails can
be cyanosis or pale .
c. Head and neck : Usually in the case
of Broncho pneumonia head and bearing are not experiencing interference .
d. Eyes : Eyes appear to be short due to lack of fluid due
to tachypnea .
e. Ear , nose , mouth , and throat : Ear normal, respiratory lobe of the
nose , the cyanosis, mucosa of the mouth dry , and difficult to swallow .
f. Chest and thoracic : On the chest there
is movement retractions intercostal, the Ronchi and WEEZING on the side of the sick .
g. Abdomen : There was a complaint wall of the
abdomen and the enlargement of the liver and the pain hit .
h. Extremities : Muscle strength tends to be weak , acral cold , pale .
i. Integumen : Dry skin , decreased turgor .
Supporting examination
a. Laboratories m
1. LEDs increase t
2. HB tends to remain / decrease
3. Blood Gas Analysis : metabolic acidosis with or without CO2 retention
b. Radiology: Looks overview
of consolidation inflammation that is diffuse or in the form
of patches that follow include alveoli are scattered .

Patoflow Bronchopneumonnia
Staphylococcal aureus and Haemofilus influezae bacteria
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Data analysis
Data Etiology Problem
DS : - DO: - Clearing the airway is
Excessive tamarind in the
ineffective
bronchi

Inflammation process

Accumulation of secretions
in the bronchi

Clearing the airway is not

effective
DS : - DO: - Impaired breathing patterns
O ₂ supply decreases

Hyperventilation

Dispneu

Chest retraction / nasal lobe

breath
 Impaired breathing patterns
DS : - DO: - Impaired fluid and electrolyte
Germs carry on the
balance
digestive tract

Gastrointestinal infections

Increased normal flora in

the intestine

Peristalsis in the intestine

Malabsorption

Diarrhea

Impaired fluid and electrolyte

balance
DS : - DO: - Activity intolerance
O ₂ supply decreases

Hypoxia

Anaerobic metabolism is
increased

Lactic acid accumulation

Fatigue

Activity intolerance
Nursing diagnoses that may appear
c. Ineffective airway clearance is associated with tracheobronchial
inflammation, edema formation, increased sputum production.
d. Ineffective breath patterns associated with inflammatory processes
in alveoli.
e. Impaired fluid and electrolyte balance associated with excess fluid
loss, decreased oral input.
f. Activity intolerance is related to oxygen insufficiency for daily
activities.

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Nursing Care Plan

PLANNING
N
NURSING DIAGNOSES PURP INTERV
O RATIONAL
OSE ENTION
1 Clean k an the airway is After 1. Au 1. An
not effectively dealing with inflammation t rakeobro 3x24 scultate ineffective
nkial , the formation of edema, an increase in the hours breath airway
production of sputum. of sounds, clearance
nursin note the can be
g breath manifested
action sounds. by
is For adventurous
expect exampl breath
ed e sounds .
effecti wheezi 2. Can me
ve ng, m udahkan t
airway krekels he patient to
with and breathe .
clear ronki. 3. Can pro
and vide patients
clear with several
breath ways to
sounds 2. Gi overcome
. ve a and control
comfort dipsnea and
able reduce air
 positio entrapment .
n for 4. Can
the improve
patient, health
for status.
exampl
e the
semi-
fowler
positio
n
3. En
courage
/ aid
abdomi
nal or
lip
breathi
ng
exercis
es

4. Co
llaborat
ion
with
doctors
in drug
adminis
tration
2 Ineffective breath patterns associated with After 1. As 1. Can
. inflammatory processes in alveoli. 3x24 sess the know the
hours frequen frequency,
of cy, depth of
nursin depth breathing
g of and chest
action breathi expansion.
is ng and 2. Can
expect chest indicate
ed to expansi the presence
be an on. of sputum
effecti abnormalitie
ve s.
breathi 2. Ob 3. Can
ng servatio know the
pattern n of sound of
with cough breathing
freque patterns decreased /
ncy and sec absent if the
and retions. airway there
depth is a small
in the 3. Au obstruction.
normal scultate 4. Can
range breath allow lung
and sounds expansion
clear / and and
clean note facilitate
lungs. adventi breathing.
tious 5. Can
breath increase
sounds. sputum
expenditure.
6. Can
facilitate
4. Ra respiratory
ise your efforts and
head increase
and secret
help drainage of
change the lung
positio segments
n. into the
bronchi.
7. Can
maximize
5. He breathing
lp the and reduce
patient breathing
to work.
breathe
deeply
and
cough
exercis
es
effectiv
ely.
 6. As
sist
chest
physiot
herapy,
postura
l
drainag
e.

7. Co
llaborat
ive
adminis
tration
of
supple
mental
oxygen.

3 Impaired fluid and electrolyte balance associated wit After 1. As 1. May

h excess fluid loss , decreased oral input . 3x24 sess indicate
hours change systemic
of s in fluid
nursin vital deficiency.
g signs. 2. Can
action indicate dire
is 2. As ctly the
expect sess adequacy of
ed skin fluid input.
to retu turgor, 3. Can
rn to mucous find out the
norma membr decrease in
l fluid ane oral enter.
and moistur 4. Can
electr e (lips, provide
olyte tongue) information
balanc . about the
e. adequacy of
3. Re liquid
cord volume.
reports 5. Can
of improve
 nausea health
/ status.
vomitin
g.

4. M
onitor
urine
input
and
output.

5. Co
llaborat
ion of
drugs
as
indicate
d.
4 Activity intolerance After 3x24 hours 1. Evacuate the 1. Can set the
is related to oxygen of nursing action patient's response ability / needs of
insufficiency for is expected to to activity. patients and facilitate
daily activities. increase tolerance the choice of
for activity. intervention.
2. Can reduce stress
2. Provide a calm and excessive
environment and stimulation, increase
limit visitors during rest.
the acute phase. 3. Can reduce
metabolic needs.

3. Explain the
importance of 4. Can m eminimalk
isti r ahat plans an fatigue and help
p engobatan and balance supply and
the need oxygen demand.
keseimban gan
activity and rest.
4. Assist self-
care activities as
needed.