Nursing Interventions Assess rate/depth of respirations and chest movement.

Rationale

Tachypnea, shallow respirations, and asymmetric ches movement are frequently present because of discomfor of moving chest wall and/or fluid in lung.

Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds, e.g., crackles, wheezes.

Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, rhonchi and wheezes are heard on inspiration and/or expiration response to fluid accumulation, thick secretions, and airway spasm/obstruction.

Elevate head of bed, change position frequently.

Lowers diaphragm, promoting chest expansion, aeratio of lung segments, mobilization and expectoration of secretions.

Assist patient with frequent deep-breathing exercises. Demonstrate/help patient learn to perform activity, e.g., splinting chest and effective coughing while in upright position. Suction as indicated (e.g., frequent or sustained cough, adventitious breath sounds, desaturation related to airway secretions). Force fluids to at least 3000 mL/day (unless contraindicated, as in heart failure). Offer warm, rather than cold, fluids. Assist with/monitor effects of nebulizer treatments and other respiratory physiotherapy, e.g., incentive spirometer, IPPB, percussion, postural drainage. Perform treatments between meals and limit fluids when appropriate.

Deep breathing facilitates maximum expansion of the lungs/smaller airways. Coughing is a natural self-clean mechanism, assisting the cilia to maintain patent airwa Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort. Stimulates cough or mechanically clears airway in patient who is unable to do so because of ineffective cough or decreased level of consciousness.

Fluids (especially warm liquids) aid in mobilization an expectoration of secretions.

Facilitates liquefaction and removal of secretions. Postural drainage may not be effective in interstitial pneumonias or those causing alveolar exudate/destruction. Coordination of treatments/schedu and oral intake reduces likelihood of vomiting with coughing, expectorations.

Administer medications as indicated: mucolytics, expectorants, bronchodilators, analgesics.

Aids in reduction of bronchospasm and mobilization o secretions. Analgesics are given to improve cough effo by reducing discomfort, but should be used cautiously because they can decrease cough effort/depress

respirations.

Provide supplemental fluids, e.g., IV, humidified oxygen, and room humidification.

Fluids are required to replace losses (including insensible) and aid in mobilization of secretions. Note: Some studies indicate that room humidification has bee found to provide minimal benefit and is thought to increase the risk of transmitting infection. Follows progress and effects of disease process/therapeutic regimen, and facilitates necessary alterations in therapy. Occasionally needed to remove mucous plugs, drain purulent secretions, and/or prevent atelectasis.

Monitor serial chest x-rays, ABGs, pulse oximetry readings.

Assist with bronchoscopy/thoracentesis, if indicated.

sess vital sign changes, e.g., increased mperature/prolonged fever, tachycardia, orthostatic potension.

Elevated temperature/prolonged fever increases metabolic rate and fluid loss through evaporation. Orthostatic BP changes and increasin tachycardia may indicate systemic fluid deficit.

ssess skin turgor, moisture of mucous membranes (lips, ngue).

Indirect indicators of adequacy of fluid volume, although oral muco membranes may be dry because of mouth breathing and supplementa oxygen. Presence of these symptoms reduces oral intake.

ote reports of nausea/vomiting.

onitor intake and output (I&O), noting color, character urine. Calculate fluid balance. Be aware of insensible ses. Weigh as indicated.

Provides information about adequacy of fluid volume and replacement needs.

orce fluids to at least 3000 mL/day or as individually propriate.

Meets basic fluid needs, reducing risk of dehydration

dminister medications as indicated, e.g., antipyretics, iemetics.

Useful in reducing fluid losses.

ovide supplemental IV fluids as necessary.

In presence of reduced intake/excessive loss, use of parenteral route may correct/prevent deficiency.

dminister medications as indicated, e.g., antipyretics, iemetics.

Useful in reducing fluid losses.

ovide supplemental IV fluids as necessary.

In presence of reduced intake/excessive loss, use of parenteral route may correct/prevent deficiency.

Pneumonia can occur at any age, although it is more common in younger children. Pneumonia accounts for 13% of all infectious illnesses in infants younger than 2 years. Newborns with pneumonia commonly present with poor feeding and irritability, as well as tachypnea, retractions, grunting, and hypoxemia. Infections with group BStreptococcus, Listeria monocytogenes, or gram-negative rods (eg, Escherichia coli, Klebsiella pneumoniae) are common causes of bacterial pneumonia. Group B streptococci infections are most often transmitted to the fetus in utero. The most commonly isolated virus is respiratory syncytial virus (RSV). Cough is the most common symptom of pneumonia in infants, along with tachypnea, retractions, and hypoxemia. These may be accompanied by congestion, fever, irritability, and decreased feeding. Streptococcus pneumoniae is by far the most common bacterial pathogen in infants aged 1-3 months. Adolescents experience similar symptoms to younger children. They may have other constitutional symptoms, such as headache, pleuritic chest pain, and vague abdominal pain. Vomiting, diarrhea, pharyngitis, and otalgia/otitis are also common in this age group. Mycoplasma pneumoniae is the most frequent cause of pneumonia among older children and adolescents.

Antibiotics given intravenously (via a drip into a vein) Oxygen therapy - to ensure the body gets the oxygen it needs Intravenous fluids - to correct dehydration or if the person is too unwell to eat or drink Physiotherapy - to help clear the sputum from the lungs.