Name: Macanlalay, Ralph Elvin R.
Section: BSN 2F-D
ASSESSMENT
Subjective:
“Haan met naglala diyay
ubo’k. Diyay plema laeng ti
pro-problemaek”
Objective:
 VS: T:37.5.2C; CR:
51BPM; BP:110/80;
RR: 21
 Coughing with
Yellowish-Brown
Secretions
 Excessive Sputum
Nursing Diagnosis:
Ineffective Airway
Clearance related to
Pneumonia as evidenced
by Excessive Sputum
EXPLANATION OF THE
OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
PROBLEM
Pneumonia is an STO: Dx: Dx: STO: (Goal Met)
inflammation of the lung Within 7-8 hours of  Assess the rate, rhythm,  Tachypnea, shallow After 7-8 hours of effective
parenchyma, associated effective nursing and depth of respiration, respirations and asymmetric nursing interventions, the
with alveolar edema and interventions, the patient chest movement, and use chest movement are patient:
congestion that impair will be able to: of accessory muscles.. frequently present because of
gas exchange. a) Understand his  Assess cough effectiveness the discomfort of moving chest a) Has a very good
Ineffective airway treatment, progress, and productivity wall and/or fluid in the lung understanding regarding
clearance can be an and disease  Assess the patient’s due to a compensatory his treatment and
acute problem. High-risk b) Identify and avoid hydration status. response to airway regarding his disease
for ineffective airway specific factors that Tx: obstruction. b) Understands what and
clearance are the aged inhibit effective  Elevate the head of the  Coughing is the most effective what not to do to inhibit
individuals who have an airway clearance bed, change position way to remove secretions. effective airway
increased c) Expel sputum frequently Pneumonia may cause thick clearance
incidence of emphysema secretions more  Assist and monitor effects and tenacious secretions in c) Is able to expel sputum
and a higher prevalence effectively patients. secretions without
of nebulizer treatment
of chronic cough or LTO:  Airway clearance is hindered difficulty and pain
Within 24-36 hours of  Administer medications, as
sputum production. with inadequate hydration and
effective nursing indicated
Edx: thickening of secretions
interventions, the patient
Tx: LTO:
will be able to:  Determine the patient’s
 Lowers the diaphragm and After 24-48 hours of effective
a) Maintain clear, open understanding of
promote chest expansion, nursing interventions, the
airways. pneumonia complications
aeration of lung segments, patient:
and their treatment
mobilization, and a) Is able to maintain clear,
regimen.
expectoration of secretions. and open open
 Teach the patient the
proper ways of coughing  Nebulizers humidify the airway
and breathing. to thin secretions and
 Review normal lung facilitates liquefaction and
function, pathology of the expectoration of secretions
condition  Bronchodilators are
medications used to facilitate
respiration by dilating the
airways
RE. Macanlalay
Name: Macanlalay, Ralph Elvin R.
Section: BSN 2F-D

Edx:
 Provides a starting point in
patient education and to
identify strengths and
weaknesses in teaching
 Patient will understand the
underlying principle and
proper techniques to keep the
airway clear of secretions.
 Promotes understanding of the
current situation and the
importance of cooperating
with the treatment regimen.

RE. Macanlalay