Objective CUES

SUBJECTIVE: “Nahihirapan na siya huminga dahil sa plema hindi niya mailabas, grabe na kasi ang ubo niyan eh”

NURSING DIAGNOSIS Ineffective Airway Clearance related to retained secretions in the bronchi secondary to pneumonia

Inference PLANNING Normally the lungs are free from secretions. Pneumonia bacteria are invading the lung parenchyma thus, producing inflammatory process. And these responses leading to filling of the alveolar sacs with exudates leading to consolidation. The airway is narrowed thus wheezes is being heard. DOB in some cases orthopnea is observed. Short term: After 1 hour of nursing intervention, the client will be able to maintain airway patency, clear breath sounds. Long Term: After 1 day of nursing intervention, the client will be able to expectorate retained secretions and maintain normal breathing pattern.

NURSING INTERVETION > establish rapport > monitor VS > suction secretions PRN > place on orthopneic position > Elevate HOB > Encourage deep breathing > give bronchodilator as ordered > refer for any abnormal changes in the body

RATIONALE .> to gain client’s and relatives trust > to obtain baseline data > to decrease secretion retained in the bronchi >to maintain patent airway >to take advantage of the gravity decrease pressure on the diaphragm. > to mobilize secretion > to moisten secretions for easy expectoration > to medically manage any complications.

EVALUATION

The client shall have maintained airway patency, clear breath sounds (goal partially met) The client shall have expectorated retained secretions and maintained normal breathing pattern (goal met)

OBJECTIVES: >DOB >Orthopnea >Wheezes on both lung fields >uses intercostal muscles upon respiration >Productive Cough

3 PRIORITIZED PROBLEMS 1. . Ineffective cerebral tissue perfusion related to interruption in blood flow on brain tissues. Ineffective airway clearance related to retained secretions in the bronchi secondary to Pneumonia 2. Impaired physical mobility related to body weakness 3.