CUES Subjective: Ang hirap huminga dahil sa ubo at sipon ko.

Barado kasi ang ilong ko tapos parang di nauubos ang plema ko kaya ubo pa din ako ng ubo, as the client verbalized. Objective: -Productive cough -Dyspnea -Colds -Facial grimace -Irritability -pallor -chills Vital signs: T: 38.1 P:110 RP:28bpm BP: O2 sat: 98%

Nursing Care Plan ANALYSIS NURSING

DIAGNOSIS Ineffective airway clearance related to retained secretions secondary to pneumonia

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. There is already a presence of increase mucus production that causes an ineffective airway clearance to the patient. Reference: Medical Surgical Nursing by Joyce Black and Jane Hokanson Hawks, 8th edition, volume 2, page 1599

GOALS AND OBJECTIVES Goal: After 8hours of nursing intervention the client will be able to improved airway clearance

NURSING INTERVENTIONS

RATIONALE

EVALUATION The client was able to expectorate retained secretions and maintain normal breathing

Objectives: After 5mins of nursing intervention the client will be able to maintain normal vital signs of: T: 36.5-37.5 P:60-100 R:16-20 BP:120/80 After 10mins of nursing intervention the client will be able to enhanced techniques in expectorating secretions

Independent: Monitor vital signs q 4 Monitor respirations and breathe sounds, noting rate and sounds.
These are

indicative of respiratory distress and/or accumulation of secretions.

Elevate head of bed

and change position of the client every 2 hours to maintain position of comfort (elevate head)
Encourage deep

Elevation of

head facilitates respiratory function by use of gravity This technique can help increase sputum clearance and decrease cough spasms. Allergens and pollutants can trigger onset of acute period.

breathing exercise

Keep environment allergen

and pollution free.

CUES Subjective:
Dahil sa kalagayan ko, nahihirapan talaga ako, huminga. Ubo at sipon ang nagpapahirap sa akin huminga, as the client verbalized.

Nursing Care Plan ANALYSIS NURSING

DIAGNOSIS Ineffective Breathing Pattern related to accumulation of bacteria in the alveolus secondary to pneumonia

Objective: -breathe with the use

- difficulty of breathing -Productive cough -facial grimace

Streptococcus pneumoniae breaks down elastin in the connective tissue of the lungs resulting to alveolar walls destruction thereby many clients experience compensatory tachypnea because of an inability to meet metabolic demands. This occurs because affected alveoli cannot effectively exchange oxygen and carbon dioxide. Joyce M. Black, Medical Surgical Nursing8th Edition 2009. (Page 1599)

GOALS AND OBJECTIVES Goal: After 8 hours of nursing intervention, the patient will be able maintain airway patency Objectives: After 30 minutes of nursing interventions, the patient will be able to: a.) be free from DOB

NURSING INTERVENTIONS

RATIONALE

EVALUATION The patient was able to maintain airway patency but with some exerted effort while breathing.

-Elevated head of bed

-Upright positioning promotes lung expansion, mobilization and expectoration of secretions to keep the airway clear. (Gulanick/Myers, 2007) -to assist client in taking control of the situation -To reduce fatigue. ( Gulanick/Myers, 2007) -Hydration decreases viscosity of secretions and aids expectoration. ( Gulanick/Myers,20 07 Upper airway patency is facilitated by upright position

--Encourage deeper respirations, use of pursed-lip technique - Provided opportunities for rest - Encouraged small but frequent oral fluid intake

-Determined best resting position for the patient e.g. patient