E. Clinical Manifestations
• Typically begins with the onset of chills, fever arising rapidly (39.5 º to 40.5 º C).
• Chest pain tingling triggered by breathing and coughing.
• Tachypnea (25-45 beats / min) accompanied by respiratory mendengur, nostril breathing
• Nadi rapid and continued
• Lip and nail cyanosis
• Shortness of breath
F. Complication
• Pleural effusion
• Hypoxaemia
• Chronic Pneumonia
• BronkaltasisAtelektasis (incomplete lung development / parts of the lungs are attacked not contain air and collapse)
• systemic complications (meningitis)
G. Examination Support
• X-rays: identify the structural distribution (eg, lobar, bronchial), may also declare abscess)
• Examination grams / culture, sputum and blood: to be able to identify all existing organisms.
• Serological examination: help in differentiating the diagnosis of specific organisms.
• Examination of lung function: to determine lung, extensive set weight and aid in the diagnosis of disease state.
• Lung Biopsy: to establish a diagnosis
• Spirometrik static: to assess the amount of air aspirated
• Bronkostopi: to establish and elevate the diagnosis of foreign bodies.
H. Management
Treatment is given based on etiology and resistance tests but because it
it takes time and pneumonia patients given treatment as soon as possible:
• Penicillin G: for staphylococcus pneumonia infection.
• Amantadine, rimantadine: for pneumonia virus infection
• Erythromycin, tetracycline, tetracycline derivatives: for pneumonia infection mikroplasma
• Recommending to bed rest until the infection is showing signs.
• Provision of oxygen in case of hypoxemia.
• In case of respiratory failure, are given sufficient nutrients to calories.
Concept of Pneumonia Patients Askep
A. Assessment
1. Activity / rest
Symptoms: weakness, fatigue, insomnia
Signs: lethargy, decreased tolerance for activity.
2. Circulation
Symptoms: the history
Signs: tachycardia, flushed appearance, or pale.
3. Food / fluid
Symptoms: loss of appetite, nausea, vomiting, history of diabetes mellitus
Signs: abdominal consistency, dry skin with poor turgor, appearance kakeksia
(Malnutrition).
4. Neurosensori
Symptoms: headache frontal regions (influenza)
Signs: mental destruction (confused)
5. Pain / comfort
Symptoms: headache, chest pain (increased by coughing), imralgia, arthralgia.
Signs: protects the affected area (sleeping on the affected side to restrict movement)
6. Breathing
Symptoms: a history of chronic UTI, tachypnea (shortness of breath), dyspnea.
Signs:
• Sputum: pink, rusty
• Perpusi: flat deaf consolidation area
• Premikus: taksil and vocals gradually increased with consolidation
• decreased breath sounds
• Color: pale / cyanotic lips and yoke
7. Security
Symptoms: a history of immune system disorders such as: AIDS, steroid use, fever.
Signs: sweating, chills repeated, shaking
Guidance / learning
Symptoms: a history of surgery, chronic alcohol use
Signs: DRG showed the average length treated 6-8 days
Repatriation plan: assistance with personal care, home maintenance tasks.
B. Nursing Diagnosis
Ineffective Breathing Pattern b.d Lung Infection
Fluid Volume Deficit b.d decrease fluid intake
C. Intervention
C1. Ineffective Breathing Pattern b.d Lung Infection
Characteristics:
Cough (both productive and non-productive) output of nasal, shortness of breath, Tachipnea, limited breath sounds, retractions, fever, diaporesis, ronchii, cyanosis, leukocytosis.
Purpose:
Children will experience an effective breathing pattern characterized by:
• The sound is clean and the pulmonary breathing the same on both sides
• Body temperature in the range from 36.5 to 37.2 OC
• The rate of breathing in the normal range
• There is no coughing, cyanosis, output of the nose, retraction and diaporesis
Intervention
1. Perform assessments every 4 hours to RR, S, and the signs of the effectiveness of the airway.
R: Evaluation and reassessment of the actions that will be / have been given. Do 2. Phisioterapi chest in scheduled
R: Removing airway secretion, prevent obstruction
3. Give Oxygen moist, assess the effectiveness of therapy
R: Increased lung tissue oxygen supply
4. Give appropriate antibiotic and antipyretic order, assess the effectiveness and side effects (rash, diarrhea)
R: Eradication of germs as causa nuisance factor
5. Make checks count thoracic HR and photo
R: Evaluation of the effectiveness of the circulation of oxygen, the evaluation of the condition of lung tissue
6. Perform suction gradually
R: Helping airway clearance
7. Record the results of pulse oximeter when installed, every 2-4 hours
R: Periodic evaluation of therapeutic efficacy / health team action.
C2. Fluid Volume Deficit b.d decrease fluid intake
Characteristics:
Loss of appetite / drinking, lethargy, fever., Vomiting, diarrhea, dry mucous membranes, poor skin turgor, decreased urine output.
Purpose:
Children get an adequate amount of fluid characterized by:
• Adequate Intake, both IV and oral
• Absence of lethargy, vomiting, diarrhea
• The body temperature within normal limits
• Urine output is adequate, BJ Urine 1008 to 1.020
Intervention:
1. Record intake and output, weight diapers for output
R: Evaluation strict intake and output requirements
2. Assess and record the temperature every 4 hours, signs of fluid deficit and condition IV line
R: Convincing the requirement for liquid
3. Urine BJ Record every 4 hours or as necessary
R: a simple objective evaluation of fluid volume deficit
4. Perform oral care every 4 hours
R: Increased clearance sal indigestion, increased appetite / drinking.
referens
Mansjoer, Arif. (2000). Capita Selekta Medicine, Volume II. Media Aesculapius. Jakarta.
Mansjoer, Arif. (2001). Capita Selekta Medicine, Volume I. Media Aesculapius. Jakarta.
Mansjoer, Arif. (2002). Capita Selekta Medicine. Jakarta. Media Aesculapius
Nanda. (2007). Nanda diagnosis: Nic and Noc.
Nursalam. (2001). Process and Documentation Nursing: Concepts and Disease. Salemba Medika. Jakarta.
Nursalam. (2005). In Nursing Infants and Children (for nurses and midwives). Salemba Medika. Jakarta.
Setiadi. (2007). Human Anatomy and Physiology. Housekeeping Science. Yogyakarta.
Soegijanto, Soegeng, (2002). Children of Medicine, Diagnosis and Implementation. Medika Salemba, Jakarta.
• Typically begins with the onset of chills, fever arising rapidly (39.5 º to 40.5 º C).
• Chest pain tingling triggered by breathing and coughing.
• Tachypnea (25-45 beats / min) accompanied by respiratory mendengur, nostril breathing
• Nadi rapid and continued
• Lip and nail cyanosis
• Shortness of breath
F. Complication
• Pleural effusion
• Hypoxaemia
• Chronic Pneumonia
• BronkaltasisAtelektasis (incomplete lung development / parts of the lungs are attacked not contain air and collapse)
• systemic complications (meningitis)
G. Examination Support
• X-rays: identify the structural distribution (eg, lobar, bronchial), may also declare abscess)
• Examination grams / culture, sputum and blood: to be able to identify all existing organisms.
• Serological examination: help in differentiating the diagnosis of specific organisms.
• Examination of lung function: to determine lung, extensive set weight and aid in the diagnosis of disease state.
• Lung Biopsy: to establish a diagnosis
• Spirometrik static: to assess the amount of air aspirated
• Bronkostopi: to establish and elevate the diagnosis of foreign bodies.
H. Management
Treatment is given based on etiology and resistance tests but because it
it takes time and pneumonia patients given treatment as soon as possible:
• Penicillin G: for staphylococcus pneumonia infection.
• Amantadine, rimantadine: for pneumonia virus infection
• Erythromycin, tetracycline, tetracycline derivatives: for pneumonia infection mikroplasma
• Recommending to bed rest until the infection is showing signs.
• Provision of oxygen in case of hypoxemia.
• In case of respiratory failure, are given sufficient nutrients to calories.
Concept of Pneumonia Patients Askep
A. Assessment
1. Activity / rest
Symptoms: weakness, fatigue, insomnia
Signs: lethargy, decreased tolerance for activity.
2. Circulation
Symptoms: the history
Signs: tachycardia, flushed appearance, or pale.
3. Food / fluid
Symptoms: loss of appetite, nausea, vomiting, history of diabetes mellitus
Signs: abdominal consistency, dry skin with poor turgor, appearance kakeksia
(Malnutrition).
4. Neurosensori
Symptoms: headache frontal regions (influenza)
Signs: mental destruction (confused)
5. Pain / comfort
Symptoms: headache, chest pain (increased by coughing), imralgia, arthralgia.
Signs: protects the affected area (sleeping on the affected side to restrict movement)
6. Breathing
Symptoms: a history of chronic UTI, tachypnea (shortness of breath), dyspnea.
Signs:
• Sputum: pink, rusty
• Perpusi: flat deaf consolidation area
• Premikus: taksil and vocals gradually increased with consolidation
• decreased breath sounds
• Color: pale / cyanotic lips and yoke
7. Security
Symptoms: a history of immune system disorders such as: AIDS, steroid use, fever.
Signs: sweating, chills repeated, shaking
Guidance / learning
Symptoms: a history of surgery, chronic alcohol use
Signs: DRG showed the average length treated 6-8 days
Repatriation plan: assistance with personal care, home maintenance tasks.
B. Nursing Diagnosis
Ineffective Breathing Pattern b.d Lung Infection
Fluid Volume Deficit b.d decrease fluid intake
C. Intervention
C1. Ineffective Breathing Pattern b.d Lung Infection
Characteristics:
Cough (both productive and non-productive) output of nasal, shortness of breath, Tachipnea, limited breath sounds, retractions, fever, diaporesis, ronchii, cyanosis, leukocytosis.
Purpose:
Children will experience an effective breathing pattern characterized by:
• The sound is clean and the pulmonary breathing the same on both sides
• Body temperature in the range from 36.5 to 37.2 OC
• The rate of breathing in the normal range
• There is no coughing, cyanosis, output of the nose, retraction and diaporesis
Intervention
1. Perform assessments every 4 hours to RR, S, and the signs of the effectiveness of the airway.
R: Evaluation and reassessment of the actions that will be / have been given. Do 2. Phisioterapi chest in scheduled
R: Removing airway secretion, prevent obstruction
3. Give Oxygen moist, assess the effectiveness of therapy
R: Increased lung tissue oxygen supply
4. Give appropriate antibiotic and antipyretic order, assess the effectiveness and side effects (rash, diarrhea)
R: Eradication of germs as causa nuisance factor
5. Make checks count thoracic HR and photo
R: Evaluation of the effectiveness of the circulation of oxygen, the evaluation of the condition of lung tissue
6. Perform suction gradually
R: Helping airway clearance
7. Record the results of pulse oximeter when installed, every 2-4 hours
R: Periodic evaluation of therapeutic efficacy / health team action.
C2. Fluid Volume Deficit b.d decrease fluid intake
Characteristics:
Loss of appetite / drinking, lethargy, fever., Vomiting, diarrhea, dry mucous membranes, poor skin turgor, decreased urine output.
Purpose:
Children get an adequate amount of fluid characterized by:
• Adequate Intake, both IV and oral
• Absence of lethargy, vomiting, diarrhea
• The body temperature within normal limits
• Urine output is adequate, BJ Urine 1008 to 1.020
Intervention:
1. Record intake and output, weight diapers for output
R: Evaluation strict intake and output requirements
2. Assess and record the temperature every 4 hours, signs of fluid deficit and condition IV line
R: Convincing the requirement for liquid
3. Urine BJ Record every 4 hours or as necessary
R: a simple objective evaluation of fluid volume deficit
4. Perform oral care every 4 hours
R: Increased clearance sal indigestion, increased appetite / drinking.
referens
Mansjoer, Arif. (2000). Capita Selekta Medicine, Volume II. Media Aesculapius. Jakarta.
Mansjoer, Arif. (2001). Capita Selekta Medicine, Volume I. Media Aesculapius. Jakarta.
Mansjoer, Arif. (2002). Capita Selekta Medicine. Jakarta. Media Aesculapius
Nanda. (2007). Nanda diagnosis: Nic and Noc.
Nursalam. (2001). Process and Documentation Nursing: Concepts and Disease. Salemba Medika. Jakarta.
Nursalam. (2005). In Nursing Infants and Children (for nurses and midwives). Salemba Medika. Jakarta.
Setiadi. (2007). Human Anatomy and Physiology. Housekeeping Science. Yogyakarta.
Soegijanto, Soegeng, (2002). Children of Medicine, Diagnosis and Implementation. Medika Salemba, Jakarta.
