Medication Dose Purpose/Action
Albuterol 5 mg Bronchodilator/dilates the airway
Prednisolone 5.61 mg Anti-inflammatory/decreases inflammation
Cholecalciferol 10 mcg Vitamin D3/Absorb calcium & phosphorus
Acetaminophen 83.84 mg Analgesic/block pain impulses
Vitals
T-38.2
P-108
R- 74
SpO2-100%
B/P- 93/72
Wgt-5.6 kg
Pneumonia
Pneumonia is an infection that inflames the
air sacs in one or both lungs. The air sacs
may fill with fluid or pus causing cough with
phlegm or pus, fever, chills, and difficulty
breathing. A variety of organisms, including
bacteria, viruses, and fungi, can cause
pneumonia.
Signs & Symptoms
-nasal flaring
-accessory muscles
-Abdominal breathing
retraction
-grunting at times
-prone position
-lethargic,
-Fatigued
Labs
WBC: 17.8, pH -7.37
RBC: 3.56, PCO2: 61
Hgb: 10.6, CO2: 36
HCT- 33.9, PO2: 63
Plat: 505
Monitor for changes in
patient level of
consciousness
Ineffective airway
clearance related to
pneumonia as evidence
by decreased energy
and fatigue
Dx test
-Chest X-ray
-Blood gases
-Culture nasal fluid
Oximetric reading
Provide oxygen
at a 2L per
minute via nasal
cannula as
directed.
Assess vital sign
every 15 minutes for
alteration in blood
pressure and heart
rate
Wean off
oxygen as
tolerated
-Patient will have appropriate gas
exchange as shown in their normal
mental condition, independent
breathing of 40 – 60 minutes,
oximeter with accepted value,
blood gases within expected range
and their standard heart rate
-Patient will not show sign of
negative respiratory distress
symptoms
Impaired gas
exchange related to
viral pneumonia as
evidence by irregular
breathing pattern,
cyanosis, and
uneasiness
Within 4 hours of nursing
intervention patient will
have a stabilized
temperature within normal
limit
Special consideration
-Assess caregiver’s
readiness to care for
patient at home
-No family culture
consideration
Continued Evaluation
Assess vital sign every 15
minutes for alteration in
blood pressure and heart rate
- Flow up blood and
respiratory culture
-
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Respiratory syncytial virus
(RSV)
RSV is a respiratory virus that affects the lung
and breathing passages, leading to inflamed
and narrowed bronchioles that collect mucus,
restricting airflow. Micronutrient such as
Vitamin D has increasingly been examined for
the role in warding off infection. (Maxwell et
al., 2012)
Risks/Predisposing Factors
Age
Premature birth
Depressed immune system
Sick sibling
Other risk factors
Contact with toy/object that
may have been touch by an
infected person
Assess skin
color, body
temperature,
capillary refill,
and difference
between central
and peripheral
cyanosis.
Evaluate
respiratory status
if there is a decline
in breathing rate
or occurrence of
apnea
Administer
prescribed
antiviral and
antipyretic
Maintain adequate
hydration to aid in
mobilization and
expectoration of
secretion
Assess patient’s
vital signs at least
every hour until
become stable.
Provide
nutritional
support to meet
increased
energy demand
and high
metabolic rate√
Suction airway as
indicated to
stimulate cough
and clear airway
Patient to maintain a
patent airway with breath
sound clearing, absence of
dyspnea, cyanosis
Remove excessive
clothing, blanket,
and linen, adjust
room temperature
Hyperthermia
related to RSV infection
as evidence by
Temperature 38.2°C,
rapid and shallow
breathing. Flushed skin
Monitor oxygen
saturation using a
continue pulse
oximeter
Provide cooling
blanket when
needed.
Return to
respiratory
baseline
= 1st diagnosis
= 2nd diagnosis
= Assessment/vital signs/dx. test/Lab result.
= nursing diagnosis
= nursing intervention
= nursing outcome
= Continued Evaluation
= Cultural/development/Special consideration
= Evidence-Based Practice
= Risks/predisposing factors
= Medication
Evidence-Based Practice
Patients with respiratory syncytial virus
infection exhibit enhanced susceptibility to
subsequent pneumococcal infections.
However, the underlying mechanisms
involved in this increased susceptibility
remains unclear. We identified potentially
novel cellular and molecular cascades
triggered by RSV infection to exacerbate
secondary pneumococcal pneumonia
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