Name: T.

Date of Admission: February 14, 2015

Age: 68 years old

CC: Community Acquired Pneumonia High risk

Room:

Attending Physician: Dr. M.S

General Objective: To facilitate the maintenance of oxygen supply to all body cells.
Assessment

Nursing
Diagnosis

Subjective cues:
Di ko mayo ka
ginhawa kag ga
sakit akon nga ulo
as verbalized by
the folks.

Ineffective airway
clearance r/t
increased
tracheobronchial
secretions 2
Community Acquired
Pneumonia High Risk

Di sya mayo
katulog kung gab.i
kay nabudlayan
sya maginhawa
as verbalized by
the folks.
Gindala sya
namon sa ospital
kay nabudlayan
gid sya
maginhawa as
verbalized by folks
Objective cues:
Temp: 36.8 C
HR: 85 bpm

Rationale

Specific
Objective
s
Within 3 days of
rendering
nursing care,
the client will
be able to
maintain a
patent airway.

Nursing Intervention

Independent:
Assess airway for
patency

Assess the level of

consciousness and skin
tone.

Auscultate lungs for

presence of normal or
adventitious breath
sounds:

Decreased or
absent breath
sounds

Rationale

Evaluation

After 3 days of
rendering effective
To check for
nursing care, the client
any
with ineffective airway
obstruction
clearance was able to
restore a patent airway
To evaluate
the changes in as evidenced by stable
gas exchange and normal vital signs
(BP, RR, PR, Temp),
which affects
clear breath sounds as
the level of
consciousness manifested by absence
and skin tone. of wheezes, cough
effectively through
capability to
expectorate all
accumulated
secretions.
May indicate
presence of
mucous plug
or other major
airway
obstruction.
May indicate
increasing

RR: 26 cpm
BP: 110/70
mmHg
Abnormal
breath
sound:
wheezing
Restlessness
and
Irritability
noted
Coughing
without
sputum
production
Dyspnea
noted

Capillary
refill: 3
seconds

Others:
Chest x-ray
revealed
progression
of bilateral
lung
pneumonia.
Pulmonary
congestion
noted. NGT
and ET tubes

Wheezing

Coarse sounds

Assess
respirations;
note quality,
rate, pattern,
depth, flaring of
nostrils, dyspnea

Assess changes
in mental status.

Assess cough for

effectiveness
and productivity.

airway
resistance.
May indicate
presence of
fluid along
larger airways.

Abnormality
indicates
respiratory
compromise.

Increasing
lethargy,
confusion,
restlessness,
irritability can
be early signs
of cerebral
hypoxia.

Consider
possible
causes for
ineffective
cough:
respiratory
muscle
fatigue,
severe
bronchospasm

still in place.
No signs of
pleural
effusion.

Gram
staining in
sputum via
endotracheal
aspirate
result: Gram
stained
smear shows
many pus
cells and few
epithelial
cells.

Culture and
sensitivity
result: No
growth after
5 days of
intubation.
ABG:
metabolic
acidosis
uncompensa
ted

Note presence of
sputum; assess
quality, color,
amount, odor,
and consistency.

, thick
tenacious
secretions,
and others.

May be a
result of
infection,
bronchitis,
chronic
smoking, and
others. A sign
of infection is
discolored
sputum (no
longer clear or
white); an
odor may be
present.

Patient
education will
vary
depending on
the acute or
chronic
disease state
as well as the
patient's
cognitive
level.

To improve

Assess patient's
knowledge of
disease process

Assist patient in
performing
coughing and
breathing
maneuvers:

Optimal positioning
(sitting position)
Use of pillow or hand
splints when coughing

Use of abdominal
muscles for more
forceful cough
Importance of
ambulation and
frequent position
changes.

Position the client in

semi-fowlers position
by elevating the head
of the bed

Encourage oral intake

of fluids within the
limits

Promote energy
conservation
techniques.

Demonstrate and
teach coughing, deep
breathing, and
splinting techniques

productivity of
the cough

These
methods help
maintain
adequate lung
expansion
thus
preventing
buildup of
secretions and
atelectasis.

To facilitate
clearing of
secretions .
It promote
better lung
expansion and
improved air
exchange.
To prevent
drying of
secretions

To prevent
fatigue

So patient will

understand
the rationale
and
appropriate
techniques to
keep the
airway clear of
secretions.

Teach client and SO

about environmental
factors that can
precipitate respiratory
problems.

To limit impact
on client's
breathing.

Increasing
PaCO2 and
decreasing
PaO2 are signs
of respiratory
failure.

To remove
sputum and
mucous plugs.

To avoid the
spread of

Collaborative :
Monitor arterial blood
gases (ABGs).

If cough is ineffective,
use nasotracheal
suctioning as needed

Institute appropriate
isolation precautions
for positive cultures

Monitor pulse oximeter

as indicated

microorganis
ms

Administer oxygen at
lowest concentration
indicated and
prescribed respiratory
medications.

If secretions cannot be
cleared, anticipate the
need for an artificial
airway (intubation).

To verify
maintenance
or
improvement
in O2
saturation

For
management
of underlying
pulmonary
condition,
respiratory
distress,
cyanosis.

To help
facilitate
removal of
tenacious
sputum.