ASSESSMENT

EXPLANATION OF THE
PROBLEM
S: Kapag inuuubo
Normally, the lungs is free
ako, hindi ko
from any secretions. The
mailabas yung plema. lungs must be clear to
allow proper exchanging
of gasses and allow
maximum lung expansion.
O:
O2 inhalation at 2
In pneumonia, the lungs is
lpm per nasal cannula filled with thick secretions
due to accumulation of
No nasal flaring
infections microorganism
noted
in the lungs. In response
to infection, the
No use of accessory
inflammatory process
muscles
causes tissue edema and
exudate formation in the
No complaints of
lungs. This would cause
dyspnea
narrowing of airways and
obstructing alveoli.
Unable to expectorate
secretions
Reference:
With crackles on both Medical Surgical Nursing:
base of the lungs
11th edition, Volume 1.
Brunner and Suddarth

OBJECTIVES
STO:
After 8 hours of nursing
intervention, patient will
be able to:

1.) Monitor respiratory rate

2.) Assessed for use of

accessory muscles, nasal

flaring and subcostal
retractions
3.) Auscultated for breath
sounds

1.) Performed gentle chest

tapping
2.) Assisted in nebulization
3.) Performed postural

drainage
4.) Positioned in semi-fowlers

Absence of dyspnea
Absence of crackles on
both base of the lungs
Expectorate secretions at
least 10 ml

EVALUATION

Fully met if:

Tx

LTO:
After 72 hours of nursing
intervention, patient will
be able to have patent
airway by means of:

RATIONALE

Dx

Expectorate secretions at
least 10 ml

Nursing Diagnosis:
Ineffective airway
clearance related to
retained secretions in
the bronchi
secondary to
pneumonia

NURSING INTERVENTION

Edx
1.) Demonstrated proper deep

breathing and coughing

exercises.
2.) Instructed to increase fluid

intake as tolerated.
3.) Instructed to do cough

exercise early in the

morning
4.) Instructed watcher to do

oral care to the patient

1.) To assess for respiratory

distress and serve as a

baseline
2.) This would indicate
problem when breathing
such as DOB
3.) To assess which part of the
lungs is filled with
secretions.
1.) To loosen lodge secretion

in the affected part of the

lungs
2.) To provide assistance and
to assess for ability to
participate in nebulization
3.) To allow secretions to
move for easy
expectoration.
4.) To facilitate maximum
chest expansion and
reducing pressure to
abdominal organs on
diaphragm.
1.) To allow increase air flow

to the lungs
2.) To mobilized secretions

lodged in the lungs for

easy expectoration
3.) Secretions accumulated

during the sleep are easier

to expectorate
4.) To clean the secretions that

accumulated in the mouth

Able to cough out

secretions at least
10 ml.
Absence of dyspnea
Absence of crackles
on both base of the
lungs

Partially met if:

Able to cough out
secretions at least
10 ml and absence
of dyspnea but will
still have crackling
sound in both lungs
Not met if:
Unable to cough
out secretions at
least 10 ml.
With episodes of
dyspnea
Crackling sounds in
both lungs