Medical Diagnosis: Bronchopneumonia

Problem: Ineffective Airway Clearance RT Retained Secretions

Assessment Nursing Diagnosis Scientific Planning Interventions Rationale Evaluation

Explanation
Subjective: (none) Ineffective Airway The inflammation Choose: 1. Monitor V/S 1. -To evaluate
Clearance RT and increased especially degree of The patient will
Objective: Retained Secretions secretions make it The patient will respiratory rate compromise demonstrate
 Appears weak & AEB Ineffective difficult to maintain a demonstrate behaviors to improve
restless Cough patent airway, which behaviors to improve 2. Auscultate breath 2. -To ascertain airway patency.
 Appears is cause by decrease airway patency. sounds, note areas status and note
tachypneic ability to expel the of progress or The patient will
 With changes in excessive mucus The patient will decreased/adventi complications maintain or establish
rate, rhythm and produced that will maintain or establish tious breath effective airway
depth of lead to extensive effective airway sounds as well as clearance AEB
breathing obstruction of the clearance AEB fremitus effective respirations
 With DOB and (+) airway. effective respirations and absence of signs
wheezes on the and absence of signs 3. To maximize of respiratory
right lung of respiratory 3. -Elevate HOB or respiratory effort distress
 Appears cyanotic distress change position and mobilize
 With (+) every 2 hours as secrections The patient will
nonproductive The patient will necessary verbalize
cough verbalize 4. To prevent understanding of
 Appears understanding of 4. Keep environment allergic reactions causative factors and
tachycardiac causative factors and allergen-free prevent recurrence
 Wide-eyed prevent recurrence of problem.
of problem. 5. To help liquefy
5. -Encourage client secretions (Change to “will” to
to increase OFI to “shall” and shift to
at least 2000 past tense)
ml/day within level
of cardiac
tolerance.
6. To promote
6. Encourage wellness
adequate rest and
limit activities to

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(ignore the Monkey)
 within client
tolerance.

7. To treat
7. Administer underlying
medications such conditions and
as bronchodilators/ mobilize
expectorants as secretions
indicated
8. To promote
8. Encourage wellness
adequate bed rest

This NCP was made with love by NursesLabs.com

(ignore the Monkey)