CUES

NURSING DIAGNOSIS

INFERENCE

Subjective:
Nahihirapang huminga
ang anak ko at may
konting plema saya kung
umuubo siya. As
verbalized by the
patients mother.

Ineffective airway
clearance related to
excessive mucus
secondary to pneunonia

Pneumonia is inflammation
of the terminal airways and
alveoli caused by acute
infection by various agents.
Pneumonia can be divided
into three
groups: community
acquired, hospital or
nursing home acquired
(nosocomial), and
pneumonia in an
immunocompromised
person.Causes include
bacteria (Streptococcus,
Staphylococcus,
Haemophilus influenzae,
Klebsiella, Legionella).
Community Acquired
Pneumonia (CAD) is
a disease in which
individuals who have not
recently
been hospitalized develop
an infection of the lungs. It
is an acute inflammatory
condition thats result from
aspiration of oropharyngeal
secretions or stomach
contents in the lungs.

Objective:
BP: 60/40
PR: 167 bpm
Temp: 37.2C
RR: 71 cpm
Tachypneac
Dyspneac
Tachycardiac
With DOB and crackel
sounds on left lung
Change in respiratory
rate and rhythm
With series of productive
cough

PLANNING
After 8 hours of nursing
inter vention the patient
would be able to:

NURSING
INTERVENTION
Independent:
Elevate head of
the bed/ change position
every 2 hours and prn.

Maintain airway patency

Demonstrate reduction of
congestion with breath
sounds clear, respirations
noiseless, improve
oxygen exchange.
Display absence of
tachypnea, dyspnea and
tachycardia

Monitor v/s signs

especially respiratory
rate, note for respiratory
distress
Monitor respirations and
breath sounds, noting
rate and sounds
Evaluates clients cough
or gag reflex and
swallowing ability
Suction
naso/tracheal/oral prn

Standby Oxygen at
bedside

RATIONALE
To take advantage of
gravity decreasing
pressure on the
diaphragm and
enhancing drainage
of/ventilation of different
lung segment

To evaluate degree of
compromise

After 8 hours of nursing

inter vention the patient:
Maintained airway
patency
Demonstrated reduction
of congestion with breath
sounds clear, respirations
noiseless, improve
oxygen exchange.
Displayed absence of
tachypnea, dyspnea and
tachycardia

Indicatives of respiratory
distress and/or
accumulation of
secretions
To determine ability to
protect own airway

Insert oral airway as

needed

To clear airway when

excessive or viscous
secretions are blocking
airway or client is unable
to swallow or cough
effectively

Advice CPT to mother

For emergency

Increase fluid intake to at

least 2000ml/day within
cardiac tolerance

To maintain anatomic
position of tongue and
natural airway, especially
when tongue/ laryngeal
edema or thick secretions
may block airway

Dependent:
Give
expectorants/bronchodol
ators as ordered

EVALUATION

Helps on secretion of
excessive mucus
Hydration can help
liquefy viscous secretions
and improve secretion
clearance

The goal is met

Aids in
reduction of
bronchospas
m and
mobilization of
secretions.