You are on page 1of 2

ASSESSMENT Subjective: Nahihirapang huminga ang anak ko at may kontingplema saya kung umuubo siya.

As verbalized by the patients mother. Objective: BP: 60/40 PR: 167 bpm Temp: 37.2C RR: 71 cpm Tachypneac Dyspneac Tachycardiac With DOB and crackel sounds on left lung Change in respiratory rate and rhythm With series of productive cough

NURSING DIAGNOSIS Ineffective airway clearance related to excessive mucus secondary to pneunonia

INFERENCE Pneumonia is inflammation of the terminal airways and alveoli caused by acute infection by various agents. Pneumonia can be divided into three groups: community acquired, hospital or nursing home acquired (nosocomial), and pneumonia in an immunocompromis ed person.Causes include bacteria (Streptococcus, Staphylococcus, Haemophilus influenzae, Klebsiella, Legionella). Community Acquired Pneumonia (CAD) is a disease in which individuals who have not recently been hospitalized develop an infection of the lungs. It is an acute inflammatory condition thats result from aspiration of

PLANNING After 8 hours of nursing inter vention the patient would be able to: Maintain airway patency Demonstrate reduction of congestion with breath sounds clear, respirations noiseless, improve oxygen exchange. Display absence of tachypnea, dyspnea and tachycardia

NURSING INTERVENTION Independent: Elevate head of the bed/ change position every 2 hours and prn.

RATIONALE To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of/ventilation of different lung segment

EVALUATION After 8 hours of nursing inter vention the patient: Maintained airway patency Demonstrated reduction of congestion with breath sounds clear, respirations noiseless, improve oxygen exchange. Displayed absence of tachypnea, dyspnea and tachycardia The goal is met

Monitor v/s signs especially respiratory rate, note for respiratory distress Monitor respirations and breath sounds, noting rate and sounds Evaluates clients cough or gag reflex and swallowing ability Suction naso/tracheal/oral prn

To evaluate degree of compromise

Indicatives of respiratory distress and/or accumulation of secretions To determine ability to protect own airway

To clear airway when excessive or viscous secretions are blocking airway or client is unable to swallow

oropharyngeal secretions or stomach contents in the lungs.

or cough effectively Standby Oxygen at bedside Insert oral airway as needed For emergency

To maintain anatomic position of tongue and natural airway, especially when tongue/ laryngeal edema or thick secretions may block airway Helps on secretion of excessive mucus Hydration can help liquefy viscous secretions and improve secretion clearance

Advice CPT to mother

Increase fluid intake to at least 2000ml/day within cardiac tolerance

Dependent: Give expectorants/bron chodolators as ordered

Aids in reduction of bronchospas m and mobilization of secretions.