Medical Diagnosis: Pneumonia

Problem: Ineffective Airway Clearance RT Retained Secretions

Assessment Nursing Scientific Planning Interventions Selected Nursing Rationale Evaluation

Diagnosis Explanation Interventions
Subjective: Ineffective Pneumonia is After 8 hours of  Identify client INDEPENDENT
“Hirap akong Airway an nursing population at 1. Monitor V/S 1. -To evaluate GOAL MET. The
huminga, gawa Clearance RT inflammation interventions the risk. especially degree of patient was able
siguro nitong Retained of the lung patient will be  Monitor respiratory rate compromise to maintain or
sakit ko.’ As Secretions as parenchyma, able to respirations establish
verbalized by the evidence by associated maintain or and breath 2. Auscultate breath 2. -To ascertain effective airway
patient abnormal rate / with alveolar establish sounds. sounds, note areas status and clearance as
depth of edema and effective airway  Evaluate of note evidenced by
Objective: respirations and congestion clearance as client’s cough decreased/adventi progress or normal
 Appears use of that impair evidence by or gag reflex tious breath complication respirations from
weak & accessory gas exchange. normal and sounds as well as s 26 to 19cpm and
restless muscles. The respirations and swallowing fremitus absence of signs
 RR= 26 cpm, inflammation absence of signs ability. of respiratory
changes in and increased of respiratory  Position head distress.
rate, rhythm secretions make distress. appropriate 3. -Elevate HOB or 3. To maximize
and depth of it difficult to for age or change position respiratory
breathing maintain a condition. every 2 hours as effort and
 With DOB patent airway,  Suction as necessary mobilize
and (+) which is cause by needed. secrections
wheezes on decrease ability  Elevate head
the right lung to expel the of bed. 4. Keep environment 4. To prevent
 Appears excessive mucus  Keep allergen allergen-free allergic
cyanotic produced that free. reactions
 With (+) will lead to  Encourage
nonproductiv extensive deep 5. -Encourage client 5. To help
e cough obstruction of breathing to increase OFI to liquefy
 Appears the airway. exercise. at least 2000 secretions
tachycardiac,  Increase fluid ml/day within level
HR = 110 intake. of cardiac
bpm  Encourage tolerance.
 Wide-eyed adequate rest
and limit 6. Encourage 6. To promote
activities to adequate rest and wellness
within client limit activities to
tolerance. within client
 Perform or tolerance.
assist client 7. to maximize
with postural 7. Encourage deep effort.
drainage and breathing exercise.
percussion as
indicated. DEPENDENT
 Assist with the 8. Administer 8. To treat
use of medications such underlying
respiratory as bronchodilators/ conditions
devices and expectorants as and moisten
treatment. indicated. and mobilize
 Support secretions
reduction or 9. To reduce
smoking 9. Suction as secretions
cessation. indicated. and help to
 Auscultate improve
breath sounds. airway.
 Administer
medications
such as
bronchodilator
s/
expectorants
as indicated
 Administer
analgesics as
prescribed to
improve cough
when pain is
inhibiting
effort.