Pneumonia Nursing Diagnosis - Diagnosa Keperawatan Pneumonia

3 Nursing Diagnosis for Pneumonia

Nursing Diagnosis for Pneumonia and Nursing Interventions for Pneumonia

1. Nursing Diagnosis Knowledge Deficit: about the condition and the need for action

Related to:

• Less exposed to information
• Less to remember
• Misinterpretation

Possible evidenced by:

• Requests for information
• Statement of misconception
• Repeat mistakes

Expected outcomes are:

• Stated understanding of disease processes and treatment conditions
• Do changes in lifestyle

Nursing Interventions for Pneumonia :

• Review of normal lung function
• Discuss aspects of the inability of the disease, duration of healing and hope of recovery
• Provide written and verbal form
• Emphasize the importance of continuing effective cough
• Emphasize the need to continue antibiotic therapy for the recommended period.

2. Nursing Diagnosis for Pneumonia : Risk for Fluid Volume Deficit

Risk factors:

• Excessive loss of fluids (fever, sweating, hyperventilation, vomiting)

Expected outcomes are:

• Balance of fluid balance
• Moist mucous membranes, normal turgor, capillary filling fast.

Nursing Interventions:

• Assess changes in vital signs
• Assess skin turgor, mucous membrane moisture
• Note the report nausea / vomiting
• Monitor input and output, note the color, character of urine
• Calculate the fluid balance
• Fluid intake of at least 2500 / day
• Give the drug as an indication: antipyretic, antiemetic
• Provide additional IV fluids as necessary

3. Nursing Diagnosis : Pain (Acute / Chronic)

Related to:

• Inflammatory lung parenchyma
• Cellular reactions against circulating toxins
• Persistent cough

Possible evidenced by:

• Chest pain
• Headache, joint pain
• Protect an area hospital
• Distraction behaviors, restlessness

Expected outcomes are:

• Cause the pain is gone / controlled
• Show relaxed, rest / sleep and increased activity quickly.

Nursing Interventions:

• Determine the characteristics of pain
• Vital Signs Monitor
• Teach relaxation techniques
• Advise and assist the patient in the technique of chest compressions during episodes of coughing.

Source : http://nandadiagnosis.blogspot.com/2012/05/3-nursing-diagnosis-for-pneumonia.html

Diagnosa Keperawatan Pneumonia

1. Ketidakefektifan Pola Nafas b.d Infeksi Paru

Karakteristik :

Batuk (baik produktif maupun non produktif) haluaran nasal, sesak nafas, Tachipnea, suara nafas terbatas, retraksi, demam, diaporesis, ronchii, cyanosis, leukositosis.

Tujuan :

Anak akan mengalami pola nafas efektif yang ditandai dengan :
- Suara nafas paru bersih dan sama pada kedua sisi
- Suhu tubuh dalam batas 36,5 – 37,2OC
- Laju nafas dalam rentang normal
- Tidak terdapat batuk, cyanosis, haluaran hidung, retraksi dan diaporesis

Intervensi

• Lakukan pengkajian tiap 4 jam terhadap RR, S, dan tanda-tanda keefektifan jalan napas.
  R : Evaluasi dan reassessment terhadap tindakan yang akan/telah diberikan.


• Lakukan Phisioterapi dada secara terjadwal
  R : Mengeluarkan sekresi jalan nafas, mencegah obstruksi


• Berikan Oksigen lembab, kaji keefektifan terapi
  R : Meningkatkan suplai oksigen jaringan paru


• Berikan antibiotik dan antipiretik sesuai order, kaji keefektifan dan efek samping (ruam, diare)
  R : Pemberantasan kuman sebagai faktor causa gangguan


• Lakukan pengecekan hitung SDM dan photo thoraks
  R : Evaluasi terhadap keefektifan sirkulasi oksigen, evaluasi kondisi jaringan paru


• Lakukan suction secara bertahap
  R : Membantu pembersihan jalan nafas


• Catat hasil pulse oximeter bila terpasang, tiap 2 – 4 jam
  R : Evaluasi berkala keberhasilan terapi/tindakan tim kesehatan.

2. Defisit Volume Cairan b.d Penurunan intake cairan

Karakteristik :

Hilangnya nafsu makan/minum, letargi, demam., muntah, diare, membrana mukosa kering, turgor kulit buruk, penurunan output urine.

Tujuan :
Anak mendapatkan sejumlah cairan yang adekuat ditandai dengan :

• Intake adekuat, baik IV maupun oral


• Tidak adanya letargi, muntah, diare


• Suhu tubuh dalam batas normal


• Urine output adekuat, BJ Urine 1.008 – 1,020

Intervensi :

• Catat intake dan output, berat diapers untuk output
  R : Evaluasi ketat kebutuhan intake dan output


• Kaji dan catat suhu setiap 4 jam, tanda devisit cairan dan kondisi IV line
  R : Meyakinkan terpenuhinya kebutuhan cairan


• Catat BJ Urine tiap 4 jam atau bila perlu
  R : Evaluasi obyektif sederhana devisit volume cairan


• Lakukan Perawatan mulut tiap 4 jam
  R : Meningkatkan bersihan sal cerna, meningkatkan nafsu makan/minum

Diagnosis lain :

1. Perubahan Nutrisi : Kurang dari kebutuhan b.d anoreksia, muntah, peningkatan konsumsi kalori sekunder terhadap infeksi


2. Perubahan rasa nyaman b.d sakit kepala, nyeri dada


3. Intoleransi aktivitas b.d distres pernafasan, latergi, penurunan intake, demam


4. Kecemasan b.d hospitalisasi, distress pernafasan

Sumber : http://wiwik-asuhan-keperawatan.blogspot.com/2009/01/pneumonia.html