Mohamed, Mohamed A.
February 19, 2021
Group 2a-1b
NCP Ineffective Airway Clearance (Actual)
Assessment Explanation of Objective Nursing Rational Evaluation
the problem intervention
SUBJECTIVE: normally the lungs are Short term: Dx : Short term goal (met):
free from secretion.
“Nahihirapan na siya Pneumonia bacteria are After 3 hours of nursing -Established rapport to patient and
- To gain the trust and The client’s respiration
ng invading the lung So . cooperation improved and difficulty of
intervention, the client’s
dahil saplema hindi n parenchyma thus, breathing was relieved.
respiration will improve -To know and determine
iyamailabas, grabe na producing inflammatory -Assessed patient's condition
kasi ang. processes. And theses
and difficulty of patient's needs
ubo niyan eh” responses leading to filling breathing will be
As verbalized by the of the alveolar sacs with relieved. -Monitored and recorded V/S -To establish base line data
mother. exudates leading to Long term goal ( met) :
consolidation. The airway Long term:
OBJECTIVES: is narrowed thus wheezes Tx: The patient have been able to
is being hard. After 8 hours of nursing maintain a patent airway.
-DOB intervention the client -To identify areas of
will maintain a patent -Auscultated lung fields, noting consolidation and determine
-Wheezes on both airway.. areas of decreased /absent airflow possible bronchospasm or
lung fields and adventitious breath sounds obstruction .
-productive cough - To mobilize secretions
- Assist patient to change position
every 30 minutes
Nursing diagnosis: -To facilitate breathing
-Elevate head of bed and align
IneffectiveAirway head in the middle
Clearance -To reduce bronchospasm
related - Administer meds as ordered and mobilize secretion
To retained
secretions
in the bronchi
secondary
to pneumonia Dx :
-Provided health teachings -To expel the mucous
regarding effective coughing and
deep breathing exercise.
-Encouraged to increase fluid
intake . - To liquefy secretions
-Encouraged steam inhalation
-To moisten secretions and
alleviate congestion
NCP Ineffective Airway Clearance (Potential )
Assessment Explanation of Objectives Nursing intervention Rational Expected
the problem outcomes
Subjective: An infection triggers Short term : Dx : Short term goal :
Nahihirapan alveolar inflammation
siyang huminga and edema. This After 3-4 hours of nursing -Established rapport to patient and So . -To gain the trust and The patient shall have
at kapag produces an area of low interventions the patient will cooperation demonstrated ease in
ventilation with normal demonstrate ease in breathing. -Assessed patient's condition breathing .
umuubo
perfusion. Capillaries -To know and determine
may become engorged with patient's needs
kasamang blood , causing stasis .
plema” as As the alveoli capillary Long term : -Monitor and record V/S
verbalized by membrane breaks down - To establish base line data
the mother. , alveoli fills with blood After 1 day of nursing Long term goal :
and exudates, resulting interventions the patient's S.O -explained to the SO the disease -to better understand he
in atelectasis . Shrunken will verbalize understanding of process and management of disease , how it was acquired The patient's S.O will
Objective: alveoli can't accomplish the causative factors that could symptoms. and how to be prevented. verbalize understanding
gas exchange. aggravate the condition and of the causative factors
-Difficulty &rapidly appropriate factors that could Tx : that could aggravate the
in breathing help the patient relive from gas condition and appropriate
- irritability exchange impairment . -Auscultated lungs for -Determine adequacy of gas factors that could help the
- restlessness crackles , consolidation and exchange and detect areas of patient relive from gas
- RR : 35 pleural friction rub. consolidation and pleural exchange impairment .
friction rub .
Nursing diagnosis:
-This signs may indicate
Impaired
-Assessed LOC, distress and hypoxia .
GasExchange
related to altered irritability .
alveolar-capillary - Determine circulatory
membrane adequacy , which is necessary
-Observed skin color and
changes due to capillary refill. for gas exchange to tissues.
pneumonia
disease process -To facilitate lung expansion
to enhance breathing.
-Perform chest physiotherapy
after nebulization.
-To dislodge the secretions,
-Administer oxygen as ordered for easy expectoration
Dx:
-Improves gas exchange
-Encouraged rest. decrease work of breathing
-Rest prevents tissue oxygen
demand and enhances tissue
oxygen perfusion .
-Encouraged elevated НОВ.
