Name: Maxyne Andrei L.

Zolayvar Section and Group: 2B Group 4

Name of CI: Dawn P. Miranda RN, MN Area: Pedia-Ward - TDHI

Nursing Pathophysiologic /
Assessent Cues Desired Outcome Nursing Intervention Rationale Evaluation
Diagnosis Schematic Diagram
Subjective:
- Pt’s guardian Definition: - Bacteria / Viral invasion After 8 hours of After 8 hours of
reports, “He has - Ineffective airway begins through the entry of the nursing care the client Independent: nursing care the client
been experiencing clearance related to causative agent in our lungs will be able to: was be able to:
difficulty of retained secretions through inspiration or
breathing for secondary to aspiration. 1. Exhibit an improved 1. Assess rate, rhythm and 1. This assessment is 1. Exhibit an improved
quite some time pneumonia, as RR, rhythm & depth, depth of respirations and crucial for identifying RR: 30, but was not
now. He evidenced by within of baseline. chest movement. any abnormalities in within of baseline.
had developed a difficulty of Multiplication of bacteria the patient's breathing GOAL NOT MET.
runny nose, breathing, runny virus; enters the lungs pattern, such as rapid
cough.” nose, cough, and breathing or shallow
- Pt’s guardian tachypnea. 2. Display a patent respirations, which 2. Display a patent
continues, “I took airway with breath may indicate airway with breath
notes of his Irritation of the lungs sounds clearing. respiratory distress or sounds clearing as
temperature ever ineffective airway evidenced by
since he was clearance. progressing to normal
admitted and findings of chest
recently his temp. Cells of the immune system 2. Assess cough auscultation &
was 36.9 C°, and I gathers in lungs to stop 3. Effectively cough up effectiveness and percussion & CXR.
noticed that he Source/Reference: infection. secretions. productivity. 2. Evaluating the GOAL MET.
was breathing T. Heather effectiveness and
fast.” Herdman, PhD, RN, productivity of the 3. Effectively cough up
FNI, and Shigemi patient's cough helps secretion as evidenced
Objective: Kamitsuru, PhD, Increased goblet cells in determining the by effective use of
Temperature: RN, FNI (2017). ability to clear airway splinting chest and
36.1 C° Nursing Diagnoses: Dependent: secretions. coughing.
Pulse Rate: Definitions and GOAL MET.
114 Classification 2018- Production of secretions
Respiratory Rate: 2020 (11th Edition). increase 1. Administer appropriate
35 Thieme medication (Mucolytic) as
O2 saturation: ordered by the physician.
100%
- Dry lips Accumulation of secretions in
- Difficulty of the airways
Name: Maxyne Andrei L. Zolayvar Section and Group: 2B Group 4
Name of CI: Dawn P. Miranda RN, MN Area: Pedia-Ward - TDHI

breathing
- O2 inhalation at
42LMP via Face
mask. Blockage of the airways

Strength:
- Strong faith in
God.
- Patient has a
supportive family.

Weaknesse:
- Patient is
experiences
difficulty
effectively
coughing up
secretions

T. Heather Herdman, PhD, RN, FNI, and Shigemi Kamitsuru, PhD, RN, FNI (2017). Nursing Diagnoses: Definitions and Classification 2018-2020 (11th Edition). Thieme

American Thoracic Society and Infectious Diseases Society of America. (2019). Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated
pneumonia. American Journal of Respiratory and Critical Care Medicine, 200(10), e45–e67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST

Jain, S., Self, W. H., Wunderink, R. G., & Fakhran, S. (2015). Community-acquired pneumonia requiring hospitalization among U.S. adults. New England Journal of Medicine, 373(5), 415–427.
https://www.nejm.org/doi/full/10.1056/NEJMoa1500245