Assessment Subjective Cues: Objective Cues: Presence of Body Weakness GCS= 11 NGT ET Tube RR= 15bpm Crackles Left

s Left base of the lungs Symmetrical Chest Expansion PNSS 1L x KVO Right Arm 1314gtts Ongoing Blood Transfusion at Left arm For RECHECKING of Hourly monitoring of O2 Saturation ABG to be followed Chest X-ray Result of

Nursing Diagnosis Ineffective airway clearance related to the accumulation of secretions as evidence by decrease in respiratory rate and NGT and ET tube attached and crackles at the left base of the lungs

Inference Irritant during inhalation due to microbial agents Inflammatory Responses Tissue Injury Vascular Responses Increase production of secretions Airway constriction Dyspnea

Planning After 8 hours of nursing interventions the patient secretions shall be mobilized and airway shall be maintained to be free of secretions as evidence by decrease secretions and clear lung sounds during auscultation

Nursing Interventions Independent: 1. Assess patient in semi fowlers position 2. Turn Patient side to side Q2 3. Perform Chest Physiotherapy(CPT) 4. Assess rate of respirations and chest movement

Rationale 1. Promoting chest expansion 2. It helps to liquefy the secretions by mobilizing 3. Is used to mobilize or loose secretions in the lungs 4. symmetrical chest movement are frequently present because of discomfort of moving chest wall or fluid in the lungs 5. Decrease airflow occurs in areas consolidated of fluid. Crackles can also occur in consolidated areas that can be heard during inspiration/expiration in response in fluid accumulation or thick secretions 1. To treat or prevent

Evaluation After 8 hours of nursing interventions the patient secretions shall be mobilized and airway shall be maintained to be free of secretions as evidence by decrease secretions and clear lung sounds during auscultation

5. Auscultate lung fields To note the areas of decrease airflow and adventitious sounds (Crackles)

Dependent: 1. Administer Salbutamol

Pneumonial Right Lung Smear shows presence of Gram + Cocci in 3 singly and in pairs with abundant leukocytes and fibrins

+ Ipratropium nebulizer Q6 PRN for DOB

bronchospasms and facilitate expectoration of mucus and airway clearance. Mechanism of Action: Salbutamol Inhibits the release of bronchoconstricting agents from mast cells, inhibits microvascular leakage, and enhances mucociliary clearance. Ipratropium It blocks muscarinic cholinergic receptors, Most likely due to actions of cyclic guanosine monophosphate (cGMP) on intracellular calcium, this result in decreased contractility of smooth muscle. Used to reduce colonization or prophylactic treatment for localized infection process. Mechanism of Action: Azithromycin binds to the 50S subunit of the 70S bacterial ribosomes, and therefore inhibits

2. Administer Meropenem 1gm TIV Q12 and c 500g TIV + Azithromycin 100cc PNSS Q6 via soluset

RNA-dependent protein synthesis in bacterial cells. Meropenem readily penetrates the cell wall of most Grampositive and Gramnegative bacteria to reach penicillin-bindingprotein (PBP) targets. The bactericidal activity of meropenem results from the inhibition of cell wall synthesis. 3. Suction Secretions PRN Collaborative: 1. Check for Chest CT Scan 2. Take a Specimen for Sputum AFB and Gram Staining Result 3. To facilitate airway clearance 1. To find the cause of lung problem such as DOB and Chest pain. 2. To distinguish presence of infection, identify specific pathogens and influence of the choice of treatment