NURSING

ASSESSMENT PLANNING NSG. INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Impaired gas After the nursing  Introduced name and  To gain patient’s trust. After the nursing
“Hirapan na po exchange related intervention, the established rapport. intervention, the
makahinga si to inflammation of patient will:  Assessed the client vital  Changes in VS may patient was able to:
tatay, di na rin po airways and alveoli signs as needed. indicate that patient is
makausap nang secondary to  Demonstrate experiencing difficulty of  Demonstrate
maayos”, as community- improved breathing. improved
verbalized by the acquired ventilation and  Assessed client’s  To gather baseline of ventilation and
SO. pneumonia (CAP) oxygenation of respirations: noted quality, the respiratory condition oxygenation of
as evidenced by tissues. rate, rhythm, depth, use of of the patient. tissues as
Objective: dyspnea, accessory muscles, ease, evidenced by
 Dyspnea tachycardia, and  Participate in and position assumed for patient’s ABG and
 Tachycardia disorientation. actions to easy breathing. O2 sat is at an
 Inability to pay maximize  Observe the color of skin,  As oxygenation and acceptable range
attention or oxygenation. mucous membranes, and perfusion become and shows lesser
remember nail beds to note the impaired, peripheral symptoms of
immediate presence of cyanosis tissues become respiratory distress.
events cyanotic. Cyanosis of
 O2 Sat: 77% nail beds may represent  Participate in
 pH: 7.28 vasoconstriction. actions to
 PaCO2: 52  Assess mental status,  Restlessness, irritation, maximize
mmHg restlessness, and confusion, and oxygenation such
 PaO2: 49 changes in the level of somnolence may reflect as relaxation
mmHg consciousness. hypoxemia and techniques and
decreased cerebral staying in bed as
V/S as follows: oxygenation and require often as possible.
 T: 38 C further intervention.
 HR: 122 bpm Check pulse oximetry
 RR: 37 bpm results with any mental
 BP: 170/100 status changes in older
mmHg adults.
 Monitor heart rate and  Tachycardia may
rhythm, and blood indicate fever and/or
pressure. dehydration. It can also
be a response to
hypoxemia—initial
hypoxia and
hypercapnia increase
BP and HR.
 Monitor body temperature.  High fever (common in
Assist with comfort bacterial pneumonia and
measures to reduce fever influenza) greatly
and chills: addition or increases metabolic
removal of bedcovers, demands and oxygen
comfortable room consumption and alters
temperature, tepid or cool cellular oxygenation.
water sponge bath.
 Monitor ABGs, pulse  Allows to check the
oximetry. progress of the disease
and to see if pulmonary
therapy or management
has been effective.
Pulse oximetry detects
changes in oxygenation.
O2 sats should be at
90% or greater.
 Maintain bedrest by  Prevents over
planning activity and rest exhaustion and reduces
periods to minimize oxygen demands.
energy use.
 Encourage the use of  Relaxation techniques
relaxation techniques and help conserve energy
diversional activities. that can be used for
effective breathing and
 coughing efforts.
 Elevate the head of the  These measures
bed and encourage promote maximum chest
frequent position changes, expansion, improve
deep breathing, and ventilation and mobilize
effective coughing. secretions.
 Administer oxygen
therapy by appropriate  The purpose of oxygen
means: nasal prongs, therapy is to maintain
mask, Venturi mask. PaO2 above 60 mmHg.
Subjective: Ineffective airway After the nursing  Introduced name and  To gain patient’s trust. After the nursing
“Nahihirapan na clearance related intervention, the established rapport. intervention, the
po ako umubo, to pleuritic pain as patient will:  Assessed the client vital  Changes in VS may patient was able to:
ang sakit na po ng evidenced by  Demonstrate signs as needed. indicate that patient is  Demonstrate
dibdib ko”, as persistent right- behaviors to experiencing difficulty of behaviors to
verbalized by the sided chest pain achieve airway breathing. achieve airway
patient. and cough with clearance.  Assess the rate, rhythm,  Tachypnea, shallow clearance such as
purulent sputum, and depth of respiration, respirations and frequently elevating
Objective: and infiltrates  Display patent chest movement, and use asymmetric chest the head of bed,
 Persistent confirmed through airway with of accessory muscles. movement are doing proper
right-sided chest x-ray. breath sounds frequently present breathing
chest pain clearing; because of the exercises. Proper
 Cough w/ absence of discomfort of moving splinting and
yellow sputum dyspnea. chest wall and/or fluid in effective coughing.
 Diminished the lung due to a
breath sounds compensatory response  Display patent
on the upper to airway obstruction. airway with
right side of  Assess cough  Coughing is the most improving breath
lung effectiveness and effective way to remove sounds; as
 Dyspnea productivity secretions. evidenced by
 Infiltrates seen  Auscultate lung fields,  noting areas of reduced
on chest x-ray decreased or absent adventitious
airflow and adventitious sounds and seen
V/S as follows: breath sounds: crackles, effectively
 T: 38 C wheezes. coughing up
 HR: 122 bpm  Observe the sputum color,  Changes in sputum secretions.
 RR: 37 bpm viscosity, and odor. characteristics may
 BP: 170/100 Report changes. indicate infection.
mmHg Sputum that is
discolored, tenacious, or
has an odor may
increase airway
resistance and warrant
further intervention.
 Assess the patient’s  Airway clearance is
hydration status. hindered with
inadequate hydration
and thickening of
secretions.
 Elevate the head of the  promote chest
bed, change position expansion, mobilization,
frequently. and expectoration of
secretions.
 Teach and assist the
patient with proper
deep-breathing
exercises.
 Deep breathing exercises   facilitates maximum
expansion of the lungs
and airways, and
improves the
productivity of cough.
 Coughing is a reflex and  It is the most helpful way
a natural self-cleaning to remove most
mechanism that assists secretions.
the cilia to maintain patent
 airways.
 Splinting   Reduces chest
discomfort and an
upright position favors
deeper and more
forceful cough effort
making it more effective.
 Suction as indicated  Stimulates cough or
mechanically clears
airway in a patient who
cannot do so because of
ineffective cough or
decreased level of
consciousness.
 Maintain adequate  Fluids, especially warm
hydration at least 3000 liquids, aid in the
mL/day unless mobilization and
contraindicated. Offer expectoration of
warm, rather than cold, secretions. Fluids help
fluids. maintain hydration and
increases ciliary action
to remove secretions,
and reduces the
viscosity of secretions.
Thinner secretions are
easier to cough out.
 Postural drainage/Chest  Helps loosen and
percussion mobilize secretions in
smaller airways that
cannot be removed by
coughing or suctioning.
 Administer medications,
as indicated.
 Mucolytics  increase or liquefy
respiratory secretions.
 Expectorants  increase productive
cough to clear the
airways.
 Bronchodilators  are medications used to
facilitate respiration by
dilating the airways.
 Analgesics  to improve cough effort
by reducing discomfort
 Monitor ABGs, pulse  Allows to check the
oximetry progress of the disease
and to see if pulmonary
therapy or management
has been effective.
Pulse oximetry detects
changes in oxygenation.
O2 sats should be at
90% or greater.
 Anticipate the need for  These measures are
supplemental oxygen or needed to correct the
intubation if the patient’s hypoxemia. Intubation is
condition deteriorates. needed for deep
suctioning efforts and
provides a source for
augmenting oxygenation