GROUP SMART :

- AGUNG WIBOWO
- AJI MARDHATILAH
- ALMAIDAH ALMANDA
- ANI SURYANI
- ARIKA NOVIRIANA
- AZIZAH
- DELA ANGGERIANI
- DELLYA NOVITA
- DESY NUR ELIANA
- DEVI PRATIWI
Pneumonia
PRELIMINARY REPORT
Definition
Pneumonia is inflammation of the lungs and
bronchioles caused by bacteria, fungi, viruses, or
aspirations due to food or foreign matter.
Pneumonia is a disease of the respiratory system
disorders of the lung tissue that requires oxygen.
Etiology
The causes of pneumonia are:
- Bacteria: Diplococcus pneumonia, staphylococcus aureus,
streptococcus.
- Viruses: Respiratory syncytial viruses, influenza viruses,
adenoviruses.
- Mycoplasma pneumonia.
- Fungi: Candida albicans, Histoplasma capsulatum.
- Aspiration: Food, amniotic fluid, foreign matter
Clinical Manifestation
- Fever
- Cough
- Anorexia
- Nausea and vomiting
- Sore throat is a complaint that often occurs in
children
Pathophysiology
Pneumonia is a secondary infection that is usually
caused by bacteria that enter the respiratory tract,
causing lung inflammation. Pneumonia bacteria can
enter through infections of the mouth and throat area.
Pneumonia bacteria penetrate the mucosal tissue
then enter the blood vessels after blood flow to the
lungs and the lining of the brain
Supported data
- Examination of lung function as a diagnostic tool
pneumonia
- Pulmonary biopsy as a diagnosis.
- Gram or culture examination, sputum, and blood as
identification of all existing organisms
- Bronchoscopy as a diagnosis and removal of foreign
bodies
Disease Management
- Oxygen administration 1-2 L / minute
- If excessive mucus secretion can be given inhalation with
normal saline and beta-agonists to improve mucociliary
transport. Correction of acid-base and electrolyte balance
disorders
- Administration of antibiotics must be by the results of
culture
NURSING CARE
REPORT
Patient’s Data

Name: Mrs.R
Gender: Female
Age: 59 years
Religion: Protestant Christianity
Education: Graduated Academic
Occupation: Civil Servant
Address: Binjai Jurman Air Flight
Hospital Entrance Date: 03-May-2017
Medical Record Number: 06.67.99.08
Assessment Date: May 9, 2017
Medical Diagnosis: Pneumonia
 FOCUS DATA
Subjective Data
- The patient said that the
cough with phlegm is thick
and difficult to remove
- The patient said shortness of
breath
- The patient has no appetite
- The patient feels nauseous
and wants to vomit
- The patient says his body is
weak
Objective Data
- The patient looks restless and weak
- The patient has difficulty breathing
- Tachypnea
- Vital sign :
 Temperature: 36,50 C
 Blood pressure: 130/90 mmHg.
 Pulse: 90 times / minute.
 Respiration: 30 times / minute.
- Dry lip mucosa
- Turgor the skin for less than 3 seconds
- Auscultation examination sound Ronchi
Nursing Diagnose
- Ineffective airway clearance related to increased viscous secretion
- Altered nutrition: less than body requirements related to inadequate
nutrition intake
INTERVENTION
Nursing Diagnose Intervention Rational

1. Ineffective airway 1) Monitor vital signs 1) The rationale is to find out the
clearance related to 2) Monitor respiration and general state of the client.
increased viscous oxygenation 2) Decreased breath sounds can
secretion 3) Auscultation of breath sounds indicate atelectasis
4) Collaboration in the 3) To note the existence of additional
administration of 2.5 mg breath sounds
nebulizer therapy 4) To smooth the airway

2. Altered nutrition: less 1) Assess the patient's ability to 1) Find out if there are any signs of
than body
requirements related swallow difficulty swallowing
to inadequate nutrition 2) Serve warm food 2) Aims to improve patient appetite
intake
3) Determine the number of 3) Aims to meet nutritional requirements
calories and the type of (Alfati, 2017)
nutrients needed
REFERENCES

Alfati, Amin. 2017. “Asuhan Keperawatan Pada Ny . R Dengan Prioritas Masalah

Kebutuhan Dasar Oksigenasi : Bersihan Nafas Tidak Efektif Di RSUP . H Adam
Malik Medan.”
Thank You
Would anyone have any questions
????????