NURSING NURSING

ASSESSMENT INFERENCE PLANNING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective: Ineffective airway Pneumonia is After 8 hours of Independent: After 8 hours of
“Nahihirapang clearance related inflammation of the nursing inter Elevate head of To take advantage nursing inter
huminga ang anak to excessive terminal airways vention the patient the bed/ change of gravity vention the patient:
ko at may mucus secondary and alveoli caused would be able to: position every 2 decreasing
kontingplema saya to pneunonia by acute infection hours and prn. pressure on the Maintained airway
kung umuubo by various agents. Maintain airway diaphragm and patency
siya.” As Pneumonia can be patency enhancing
verbalized by the divided into three drainage Demonstrated
patient’s mother. groups: community Demonstrate of/ventilation of reduction of
acquired, hospital reduction of different lung congestion with
Objective: or nursing home congestion with segment breath sounds
BP: 60/40 acquired breath sounds clear, respirations
PR: 167 bpm (nosocomial), and clear, respirations noiseless, improve
Temp: 37.2°C pneumonia in an noiseless, improve oxygen exchange.
RR: 71 cpm immunocompromis oxygen exchange. Monitor v/s signs To evaluate
ed person.Causes especially degree of Displayed absence
Tachypneac include bacteria Display absence of respiratory rate, compromise of tachypnea,
(Streptococcus, tachypnea, note for respiratory dyspnea and
Dyspneac Staphylococcus, dyspnea and distress tachycardia
Haemophilus tachycardia
Tachycardiac influenzae, Monitor The goal is met
Klebsiella, respirations and Indicatives of
With DOB and Legionella). breath sounds, respiratory distress
crackel sounds on Community noting rate and and/or
left lung Acquired sounds accumulation of
Pneumonia (CAD) secretions
Change in is a disease in Evaluates client’s
respiratory rate which individuals cough or gag To determine
and rhythm who have not reflex and ability to protect
recently swallowing ability own airway
With series of been hospitalized
productive cough develop Suction
an infection of naso/tracheal/oral To clear airway
the lungs. It is an prn when excessive or
acute inflammatory viscous secretions
condition that’s are blocking
result from airway or client is
aspiration of unable to swallow
oropharyngeal or cough
secretions or effectively
stomach contents Standby Oxygen
in the lungs. at bedside For emergency

Insert oral airway

as needed To maintain
anatomic position
of tongue and
natural airway,
especially when
tongue/ laryngeal
edema or thick
secretions may
block airway
Advice CPT to
mother Helps on secretion
of excessive
mucus
Increase fluid
intake to at least Hydration can help
2000ml/day within liquefy viscous
cardiac tolerance secretions and
improve secretion
clearance

Dependent:
Give Aids in
expectorants/bron reduction of
chodolators as bronchospas
ordered m and
mobilization of
secretions.