NURSING PROBLEM

S>
Minsannahihirapan pa
rinsiyanghumingalalona
apagderetsosiyangnagd
edede.Kasesiguro may
natira pa sabaganiyang
secretion
O > Minimal coughing
episode noted
characterized as non
productive.Minimal
wheezing noted after
spontaneous
breastfeeding.With
capillary refill of 1-2
seconds.No chest
indrawing.No nasal
flaring.Equal bilateral
chest movement
noted.OccasionalTachy
cardia.Inability to
expectorate.Chest x-ray
result of positive in
pneumonia revealed
both lower lungs.

EXPLANATION OF
THE PROBLEM
> Ineffective airway
clearance is the inability
to clear secretions from
the lung fields. This is
caused by entry of
micro organisms into
the lungs through
aspiration. The body
detects the presence of
pathogen that tries to
expel micro organisms
out of the body.
Pneumonia may be
acquired by intrauterine
(e.g.
transplacentalhematoge
nous, ascending
from birth canal),
intrapartum (e.g
aspiration) or postnatal
routes (e.g.
hematogenous,
environmental). The
pathogens include
mainly bacteria,
followed by viruses and
fungi

OBJECTIVES
LTO > Within 72 hours of
nursing interventions, the
patient will be able to
have a effective airway
clearance and no
episodes of any
respiratory distress as
manifested by :

INTERVENTIONS
>Monitor body
temperature.

>Monitor Respiratory
Status

a.) Absence of
coughing episodes
b.) No signs of
distress noted
c.) No wheezing
heard after having
a breastfeed
STO >Within 48 hours of
nursing intervention, the
patient will :
a.) Have a clear
breath sounds
upon auscultation.
b.) Have a lesser

RATIONALE

EVALUATION

> High fever greatly

increases metabolic
demands and oxygen
consumption and
alters cellular
oxygenation.

LTO >Goal Fully

met if 3 out of the 3
criteria were met by
the patient

> Manifestation of
respiratory distress is
dependent on
indicative of the
degree of lung
involvement
and underlying
general status.

>Monitor and
Auscultate breath
sounds

> Helps assists in

evaluating prescribed
treatments and client
outcomes.

>Administer
medication as
prescribed
(Cefotaxime)

>respiratory therapy
treatments may be
used to open
constricted airways
and will combat
microbes.

Goal Partially met if

2out of the 3 criteria
were met by the
patient
Goal not met none
of the criteria were
not met by the
patient
STO >
Goal Fully met if 2
out of 2 criteria
were met by the
patient.
Goal Partially met if
1out of 2 criteria
were met by the
patient
Goal not met none

A > Ineffective airway

clearance related to
retained secretions
secondary to
pneumonia

which induce an
inflammatory pulmonary
condition (1,8). This
may cause epithelial
injury
to the airways, leakage
of proteinaceous fluid
into the alveoli and
interstitium, leading to
surfactant deficiency or
dysfunction.

coughing episode
>Elevate head by
cuddling and change
positions frequently.

>Promotes chest
expansion that keep
airway clear.

>Adavise mother to
increase fluid of baby
by BreastFeeding

>Enhance evacuation
of secretions and for
hydration

>Advise mother not

to expose baby in
polluted areas.

>Prevent and protect

baby from acquiring
other disease that
may render more
complications.

> Limit visitors as

indicated

>Reduces likelihood
of exposure to other
infectiouspathogens.

of the criteria were

not met by the
patient