Nursing Diagnosis : Ineffective Breathing Pattern
Ineffective breathing pattern related to lung infection
Cough (either productive or non productive) nasal output, shortness of breath, tachipnea, limited breath sounds, retractions, fever, diaporesis, ronchii, cyanosis, leukocytosis.
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.