ASSESSMENT NURSING DIAGNOSIS INFERENCE PLANNING NURSING RATIONALE EVALUATION

INTERVENTION
Subjective: Ineffective airway Pneumonia is After 8 hours of nursing Elevate head of the To take After 8 hours
“Nahihirapang clearance related to inflammation of the intervention the patient bed/ change position advantage of of nursing
huminga ang anak excessive mucus terminal airways and would be able to: every 2 hours and prn. gravity intervention
ko at may secondary to alveoli caused by acute Maintain airway Monitor v/s signs decreasing the patient:
kontingplema pneumonia infection by various patency Demonstrate especially respiratory pressure on Maintained
saya kung Independent: agents. Pneumonia can reduction of congestion rate, note for the airway
umuubo be divided into three with breath sounds respiratory distress diaphragm patency
siya.” As groups: clear, respirations Monitor respirations and Demonstrate
verbalized by the Community acquired, noiseless, improve and breath sounds, enhancing d reduction of
Patient’s mother. hospital or nursing home oxygen exchange. noting rate and sounds drainage congestion
Objective: acquired (nosocomial), Display absence of Evaluates client’s of/ventilatio with breath
and pneumonia in an tachypnea, dyspnea cough or gag reflex and n of different sounds clear,
BP: 60/40 immune compromised and tachycardia swallowing ability lung segment respirations
PR: 167 bpm person. Suction To evaluate noiseless,
Temp: 37.2°C Causes include bacteria naso/tracheal/oral prn degree of improve
RR: 71 cpm (Streptococcus, compromise oxygen
Tachypnea Staphylococcus, Indicatives of exchange.
Dyspnea Haemophilus influenza, respiratory Displayed
Tachycardia With Klebsiella, Legionella). distress absence of
DOB and crackled Community Acquired and/or tachypnea,
sounds on left Pneumonia (CAD) is a accumulatio dyspnea and
lung Change in disease in which n of tachycardia
respiratory rate individuals who have not secretions To The goal is
and rhythm With recently been determine met
series of hospitalized develop an ability to
productive cough infection of the lungs. It is protect own
an acute inflammatory airway To
condition that’s clear airway
result from aspiration of when
excessive or
viscous
secretions
are blocking
airway or
client is
unable to
swallow
Increase HORT TERM o gain patient’s SHORT TERM
inrespiratory rate After 2-3hours of Establish rapport trust andcooperation2. Client shallverbalize
of 31 cpm nursingintervention, withpatient2. understanding
patient will beable to Increased mucus anddemonstrate proper
verbalizeunderstandin Instruct patient andsputum deepbreathing
Shortness of g anddemonstrate toincrease oral secretionscan lead technique tofacilitate
breath(orthopnea proper deepbreathing fluidintake to 8- todehydration;increase properoxygenation to
) technique tofacilitate 10glasses3. d waterintake can alleviatehyperventilatio
proper oxygenationto helpdissolve n
alleviate Instruct patient to secretions3. LONGTERM
hyperventilation dodeep Patient shall be free of
Dyspnea LONG TERM breathingexercise Deep breathingexercise cyanosis and
After 2-3 days of afterdemonstratingprope increasesoxygen intake establishnormal
nursingintervention, r technique4. andcan help breathing patter
Use of patient will befree of alleviatedyspnea4.
accessorymuscles cyanosis andestablish Keep
inbreathing normal environmentallergen free Presence may
breathingpattern (dust,feather triggerallergic
pillows,smoke, pollen)5. responsethat may
causefurther increase
Altered Take and VS6. inmucus secretion5.
chestexcursion
Suction To get baseline data6.
naso,tracheal/oral PRN7.
Nasal Flaring These maycompromise
Educate proper airway.A
handwashing8. distendedabdomen
caninterfere
Increased
Position the patient in withnormal
anterior-posterior
semi fowler’s diaphragmexpansion7.
diamet
position9.
To increase feeling of
Encourage patient toeat comfort8.
nutritious foodssuch as
green leafyvegetables To enable the bodyto
and leanmeat10. recuperate andrepair9.

Review client’s chest To prevent

To prevent
allergicreactions that
cancause
respiratorydistre