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CUES NURSING RATIONALE PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVETION

SUBJECTIVE: Ineffective Normally the Short term: • Establis • to gain


Airway lungs are free h rapport client’s and The client shall
“Nahihirapan na siya Clearance from After 1 hour relatives have
huminga dahil sa related to secretions. of nursing maintained
trust
plema hindi niya
retained Pneumonia intervention, • Monitor • to airway
mailabas, grabe na
kasi ang ubo niyan eh”
secretions in bacteria are the client will VS obtain patency, clear
the bronchi invading the be able to baseline breath sounds
secondary to lung maintain data (goal partially
OBJECTIVES: pneumonia parenchyma airway • Suction • to met)
thus, patency, clear secretions decrease
producing breath PRN secretion
• DOB
inflammatory sounds. retained in The client shall
• Wheezes on process. And have
both lung the bronchi
these • Place expectorated
fields responses Long Term: retained
• Productive on • to
leading to orthopneic maintain secretions and
Cough filling of the After 1 day of maintained
position patent
alveolar sacs nursing airway normal
with exudates intervention, • Elevate breathing
leading to the client will HOB • to take pattern
consolidation. be able to advantage (goal met)
The airway is expectorate of the
narrowed thus retained gravity
wheezes is secretions decrease
being heard. and maintain pressure
DOB in some normal on the
cases breathing
orthopnea is pattern. diaphragm.
observed.

• Encoura
ge deep • to
breathing mobilize
secretion
• Give
bronchodila
tor as • to
ordered moisten
secretions
for easy
• Refer expectorati
for any on
abnormal
changes in • to
the body medically
manage
any
complicatio
ns.

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