1

Malnutrition,
Assessment
Nursing Diagnosis Desired Outcome Nursing
Intervention
Rationale Outcome
Subjective:
Lagi lang siyang
nakahiga kasi
nahihirapan siyang
huminga at hinihingal
siya pero umuupo
siya pag kaya niya.
as verbalize by his
wife.

Objective:

T= 36.4 C
PR= 86 bpm
RR= 28 cpm
(Shallow)
BP= 140/80 mmHg


Physical
Assessment:

-Dyspnea.

-Symmetric
movement of chest
noted.

-Skin is intact.

-No lesions noted.

-No tenderness when
palpated.
INEFFECTIVE
AIRWAY
CLEARANCE

Related to:

Bronchospasm and
fatigue.


Secondary to:

Chronic Obstructive
Pulmonary Disease,
Community-Acquired
Pneumonia and
Pulmonary
Tuberculosis.


Possibly evidenced
by:

Tachypnea, shallow
respiration, dyspnea,
pallor, nasal
flaring,crackles and
wheezes and
abnormal use of
accessory muscle.

Short Term:
During the first 15
minutes of duty the
patient will verbalize
comfort and
demonstrate effective
breathing techniques.

Long Term:

During the 8 hours of
nursing intervention,
the client will:

Maintain patent
airway with breath
sounds clear.

Demonstrate
behaviors to improve
airway clearance by
effective coughing.

Respiratory rate is
within normal range.

Fever is not present.

Take all his
medication.

Maintained in a
minimal oxygen
support.
Independent:

-Assess and monitor
clients vital sign
paying attention to
respiration. Note the
pattern, depth,
volume.


-Auscultate lung
fields, noting area
with
decreased/absent
breath sounds and
adnetitous breath
sounds.

- Assess skin
complexion for pallor
and/or cyanosis

-Elevate head of bed.






-Educate/help the
client with deep
breathing exercises.




- Breathing pattern is
vital for clients
survival and may
result to poor tissue
perfusion.



-Decreased airflow
occurs in areas
consolidated with
fluids.




-manifestation of poor
tissue perfusion


-Lowers
diaphragm,promoting
chest expansion and
aeration of lung
segments.


-Deep breathing
facilitates maximum
expansion of the
lungs/smaller
airways.

2


-Decreased chest
expansion observed
and there is an
increased tactile
fremitus.

-Upon auscultation,
crackles and
wheezes heard.

-Productive cough
and used of
accessory breathing
muscles.

-Barrel chest.

-There is minimal
flaring of nares.

-Cool and clammy
skin.

-Pale skin color,
buccal mucosa and
conjunctiva.

-3 seconds delayed
capillary refill test.

-Slight clubbing of
finger nails.

-Weakness.


Not develop any
other complication.
-Demonstrate/assist
the client to perform
activities like splinting
chest and effective
coughing while in
upright position.





-Force fluids to
atleast 3000Ml/day.
Offer warm,rather
than cold fluids.


Collaborative

-Assist with/monitor
effects of nebulizer
treatments. Perform
treatments between
meals and limits
fluids when
appropriate.





-Administer
medications as
indicated.


-Coughing is a
natural self-clearing
mechanism,assisting
the cilia to maintain
patent airways.
Splinting reduces
chest discomfort and
upright position
favors deeper more
forceful cough effort.

-Fluids especially
warm liquids aid in
mobilization and
expectoration of
secretions.



-Facilitates
liquefaction and
removal of
secretions.
Coordination of
treatments/schedules
and oral intake
reduces likelihood of
vomiting with
coughing,
expectorations.

-Aids in reduction of
bronchospasm and
mobilization of
secretions.

3

-Fatigue.

-Lethargic. GCS of
11.

Laboratory:

-Decreased
hemoglobin(11.1 g/dl)

-Decreased
hematocrit (0.33)

-Decreased
lymphocytes (18%)

-Increased
Segmenters(82%)

-(+) PTB on chest x-
ray

-Decreased
potassium
(2.97 mmol/L)

-Compensated
Respiratory Acidosis
(pCO2 53.2 mmHg
and p02 165.5 mmHg
; pH 7.385)
-Provide
supplemental fluids
(IV and humidified
oxygen).

-Monitor laboratory
and radiology results
(cbc,pulse oximetry,
ABGs, chest x-rays
and CT scan.)


-Suction as indicated.
-Fluids are required
to replace losses and
aid in mobilization of
secretions.

-Follows progress
and effects of disease
process/therapeutic
regimen and
facilitates necessary
alterations in therapy.

-Stimulates cough or
mechanically clears
airway in patient who
is unable to do so
because of ineffective
cough or decreased
LOC.



4

Assessment Nursing Diagnosis Desired Outcome Nursing
Intervention
Rationale Outcome
Subjective:
Lagi lang siyang
nakahiga kasi
nahihirapan siyang
huminga at hinihingal
siya pero umuupo
siya pag kaya niya.
as verbalize by
clients wife.

Objective:

T= 36.4 C
PR= 86 bpm
RR= 28 cpm
(Shallow)
BP= 140/80 mmHg


Physical
Assessment:

-Dyspnea.

-Symmetric
movement of chest
noted.

-Skin is intact.

-No lesions noted.

-No tenderness when
palpated.
ACTIVITY
INTOLERANCE

Related to:

General weakness
and imbalance
between oxygen
supply and demand


Secondary to:

Chronic Obstructive
Pulmonary Disease,
Community-Acquired
Pneumonia and
Pulmonary
Tuberculosis.


Possibly evidenced
by:

Verbal reports of
weakness, fatigue,
exhaustion.
Exertional dyspnea
and tachypnea.
Short Term:
During the first 15
minutes of duty the
patient will verbalize
comfort and
cooperate to nursing
procedures with
minimal effort and will
respond positively to
assisted ADLs.

Long Term:

During the 8 hours of
nursing intervention,
the client will:

Report/demonstrate a
measurable increase
in tolerance to activity
with absence of
dyspnea and
excessive fatigue.

Vital signs within
patient acceptable
range.
Independent:

-Evaluate patients
response to activity.
Note reports of
dyspnea,increased
weakness/fatigue and
changes in vital signs
during and after
activities.

-Provide quiet
environment and limit
visitors during acute
phase as
indicated.Encourage
use of stress
management and
diversional activities
as appropriate.

-Explain importance
of rest in treatment
plan and necessity for
balancing activities
with rest.










-Establish patients
capabilities/needs
and facilitates choice
of intervention.





-Reduce stress and
excess stimulation,
promoting rest.







-Bedrest is
maintained during
acute phase to
decrease metabolic
demands thus
conserving energy for
healing. Activity
restrictions thereafter
determined by
individual patient
response to activity
and resolution of
respiratory

5


-Decreased chest
expansion observed
and there is an
increased tactile
fremitus.

-Upon auscultation,
crackles and
wheezes heard.

-Productive cough
and used of
accessory breathing
muscles.

-Barrel chest.

-There is minimal
flaring of nares.

-Cool and clammy
skin.

-Pale skin color,
buccal mucosa and
conjunctiva.

-3 seconds delayed
capillary refill test.

-Slight clubbing of
finger nails.

-Weakness.



-Assist patient to
assume comfortable
position for
rest/sleep.





-Assist with self care
activities as
necessary. Provide
for progressive
increase in activities
during recovery
phase.
insufficiency.

-Patient may be
comfortable with
head and bed
elevated, sleeping in
chair or leaning
forward on overhead
table with pillow
support.

-Minimizes
exhaustion and helps
balance oxygen
supply and demand.
6

-Fatigue.

-Lethargic. GCS of
11.

Laboratory:

-Decreased
hemoglobin(11.1 g/dl)

-Decreased
hematocrit (0.33)

-Decreased
lymphocytes (18%)

-Increased
Segmenters(82%)

-(+) PTB on chest x-
ray

-Decreased
potassium
(2.97 mmol/L)

-Compensated
Respiratory Acidosis
(pCO2 53.2 mmHg
and p02 165.5 mmHg
; pH 7.385)



7

Assessment Nursing Diagnosis Desired Outcome Nursing
Intervention
Rationale Outcome
Subjective:
Lagi lang siyang
nakahiga kasi
nahihirapan siyang
huminga at hinihingal
siya pero umuupo
siya pag kaya niya.
as verbalize by
clients wife.

Objective:

T= 36.4 C
PR= 86 bpm
RR= 28 cpm
(Shallow)
BP= 140/80 mmHg


Physical
Assessment:

-Dyspnea.

-Symmetric
movement of chest
noted.

-Skin is intact.

-No lesions noted.

-No tenderness when
palpated.
IMPAIRED GAS
EXCHANGE

Related to:

Alveolar-capillary
membrane changes.
Altered oxygen-
carrying capacity of
blood.
Altered delivery of
oxygen.


Secondary to:

Chronic Obstructive
Pulmonary Disease,
Community-Acquired
Pneumonia and
Pulmonary
Tuberculosis.

Possibly evidenced
by:
Dyspnea, lethargy
and pallor.
Short Term:
During the first 15
minutes of duty the
patient will verbalize
comfort and
demonstrate effective
breathing techniques.

Long Term:

During the 8 hours of
nursing intervention,
the client will:

Demonstrate
improved ventilation
and oxygenation of
tissues by ABGs
within patient
acceptable range and
absence of symptoms
of respiratory
distress.

Participate in actions
to maximize
oxygenation.
Independent:

-Assess respiratory
rate,depth and ease.







-Observe color of
skin, mucous
membrane, nailbeds
noting presence of
cyanosis.





-Assess mental
status.





-Monitor heart rate
and rhythm.






-Manifestation of
respiratory distress
are dependent on/
and indicative of the
degree of lung
involvement and
underlying general
health status.

-Cyanosis of nailbed
may represent
vasoconstriction or
bodys response to
fever or chills.
Cyanosis of buccal
mucosa, earlobes is
indicative of systemic
hypoxemia.

-Restlessness,
irritation, confusion,
and somnolence may
reflect hypoxemia/
decreased cerebral
oxygenation.

-Tachycardia is
usually present in
response to fever or
dehydration but may
represent a response
to hypoxemia.

8


-Decreased chest
expansion observed
and there is an
increased tactile
fremitus.

-Upon auscultation,
crackles and
wheezes heard.

-Productive cough
and used of
accessory breathing
muscles.

-Barrel chest.

-There is minimal
flaring of nares.

-Cool and clammy
skin.

-Pale skin color,
buccal mucosa and
conjunctiva.

-3 seconds delayed
capillary refill test.

-Slight clubbing of
finger nails.

-Weakness.

-Monitor body
temperature.


-Maintain bedrest.





-Elevate head and
encourage frequent
position changes,
deep breathing and
effective coughing.

-Assess level of
anxiety. Encourage
verbalization or
signage of
concerns/feelings.


-Observe
deterioration in
condition.





Collaborative:

-Monitor ABGs,
pulse oximetry.

-High fever greatly
affects metabolic
demands.

-Prevents
overexhaustion and
reduce oxygen
demands to facilitate
resolution of infection.

-To promote maximal
inspiration and
enhance
expectoration of
secretions.

-Anxiety is a
manifestation of
psychological
concerns and
physiological
response to hypoxia.

-Shock and
pulmonary edema are
the most common
causes of death in
pneumonia and
require immediate
medical intervention.



-Follows progress of
disease process and
facilitates alternations
9

-Fatigue.

-Lethargic. GCS of
11.

Laboratory:

-Decreased
hemoglobin(11.1 g/dl)

-Decreased
hematocrit (0.33)

-Decreased
lymphocytes (18%)

-Increased
Segmenters(82%)

-(+) PTB on chest x-
ray

-Decreased
potassium
(2.97 mmol/L)

-Compensated
Respiratory Acidosis
(pCO2 53.2 mmHg
and p02 165.5 mmHg
; pH 7.385)



-Administration of
appropriate oxygen
therapy. (Nasal
prongs in patients
case)
in pulmonary therapy.

-The purpose of
oxygen therapy is to
maintain Pa02 above
60mmHg. Oxygen is
administered by the
method that provides
appropriate delivery
within patients
tolerance.


10

Assessment Nursing Diagnosis Desired Outcome Nursing
Intervention
Rationale Outcome
Subjective:
Lagi lang siyang
nakahiga kasi
nahihirapan siyang
huminga at hinihingal
siya pero umuupo
siya pag kaya niya.
as verbalize by his
wife.

Objective:

T= 36.4 C
PR= 86 bpm
RR= 28 cpm
(Shallow)
BP= 140/80 mmHg


Physical
Assessment:

-Dyspnea.

-Symmetric
movement of chest
noted.

-Skin is intact.

-No lesions noted.

-No tenderness when
palpated.
RISK FOR SPREAD
OF INFECTION

Related to:

Presence of existing
infection. decreased
ciliary action and
stasis of respiratory
secretions.


Secondary to:

Chronic Obstructive
Pulmonary Disease,
Community-Acquired
Pneumonia and
Pulmonary
Tuberculosis.

Short Term:

During first 15
minutes of duty
patient will be aware
of factors that can
contribute to spread
of infection.

Long Term:

During the 8 hours of
nursing intervention,
the client will:

Achieve timely
resolution of current
infection without
complications.

Knowledge: Infection
Control

Identify interventions
to prevent/reduce
risk/spread
of/secondary
infection.


Independent:

-Monitor vital signs
closely, especially
during initiation of
therapy.


-Instruct patient
concerning the
disposition of
secretions (e.g.,
raising and
expectorating versus
swallowing) and
reporting changes in
color, amount, odor of
secretions.



-Demonstrate/
encourage good
handwashing
technique.

-Change position
frequently and
provide good
pulmonary toilet.

-Limit visitors as
indicated.



-During this period of
time, potentially fatal
complications
(hypotension/shock)
may develop.

-Although patient may
find expectoration
offensive and attempt to
limit or avoid it, it is
essential that sputum
be disposed of in a safe
manner. Changes in
characteristics of
sputum reflect
resolution of pneumonia
or development of
secondary infection.

-Effective means of
reducing spread or
acquisition of infection.


-Promotes
expectoration, clearing
of infection.


-Reduces likelihood of
exposure to other
infectious pathogens.

11


-Decreased chest
expansion observed
and there is an
increased tactile
fremitus.

-Upon auscultation,
crackles and
wheezes heard.

-Productive cough
and used of
accessory breathing
muscles.

-Barrel chest.

-There is minimal
flaring of nares.

-Cool and clammy
skin.

-Pale skin color,
buccal mucosa and
conjunctiva.

-3 seconds delayed
capillary refill test.

-Slight clubbing of
finger nails.

-Weakness.

-Institute isolation
precautions as
individually
appropriate.








-Encourage adequate
rest balanced with
moderate activity.

-Promote adequate
nutritional intake.


-Monitor
effectiveness of
antimicrobial therapy.



-Investigate sudden
changes/deterioration
in condition, such as
increasing chest pain,
extra heart sounds,
altered sensorium,
recurring fever,
changes in sputum
characteristics.

-Dependent on type of
infection, response to
antibiotics, patients
general health, and
development of
complications, isolation
techniques may be
desired to prevent
spread/protect patient
from other infectious
processes.

-Facilitates healing
process and enhances
natural resistance.

-Signs of improvement
in condition should
occur within 2448 hr.

-Delayed recovery or
increase in severity of
symptoms suggests
resistance to antibiotics
or secondary infection.

-Complications affecting
any/all organ systems
include lung
abscess/empyema,
bacteremia,
pericarditis/endocarditis,
meningitis/encephalitis,
and superinfections.


12

-Fatigue.

-Lethargic. GCS of
11.

Laboratory:

-Decreased
hemoglobin(11.1
g/dl)

-Decreased
hematocrit (0.33)

-Decreased
lymphocytes (18%)

-Increased
Segmenters(82%)

-(+) PTB on chest x-
ray

-Decreased
potassium
(2.97 mmol/L)

-Compensated
Respiratory Acidosis
(pCO2 53.2 mmHg
and p02 165.5
mmHg ; pH 7.385)
-Administer
antimicrobials as
indicated by results of
sputum/blood
cultures: e.g.,
penicillins:
erythromycin (E-
Mycin), tetracycline
(Achromycin),
doxycycline hyclate
(Vibramycin),
amikacin (Amikin);
cephalosporins:
ceftriaxone
(Rocephin);
amantadine
(Symmetrel);
sparfloxacin (Zagam);
macrolide derivatives,
e.g, azithromycin
(Zithromax).
-These drugs are used
to combat most of the
microbial pneumonias.
Combinations of
antiviral and antifungal
agents may be used
when the pneumonia is
a result of mixed
organisms. Vancomycin
and third-generation
cephalosporins are the
treatment of choice for
penicillin-resistant
streptococcal
pneumonia.


13

Assessment Nursing Diagnosis Desired Outcome Nursing
Intervention
Rationale Outcome
Subjective:

Nahirapan siyang
lumunok at kumain
kaya nilagyan siya ng
NGT. Minsan,
humihingi pa rin siya
ng kape o gatas pero
naka NGT na siya.
As verbalize by
patients wife.

Objective:

T= 36.4 C
PR= 86 bpm
RR= 28 cpm
(Shallow)
BP= 140/80 mmHg


Physical
Assessment:

-Difficulty on
swallowing.

-Dyspnea.

-Symmetric
movement of chest
noted.

-Skin is intact.
RISK FOR
ASPIRATION

Related to:

Copious and thick
secretion.
Difficulty on
swallowing.


Secondary to:

Chronic Obstructive
Pulmonary Disease,
Community-Acquired
Pneumonia and
Pulmonary
Tuberculosis.

Possibly evidence
by:

Dyspnea. Abnormal
breath sounds.
Lesser gag reflex.
Short term:

After 15 minutes of
nursing intervention
patients will be aware
of precautionary
measures to avoid
possible aspiration.


Long term:

After 8 hours of
nursing intervention
the patient will:

Maintain patent
airway with clear
breath sounds.

Demonstrate
behaviors to improve
airway clearance
within level of
ability/situation.
Independent:

-Assess respiratory
rate,depth and ease.







-Elevate head of bed
30-45 degrees.



-Encourage
swallowing if the
patient is able.


Collaborative:

-Suction oral and
nasal cavities. Note
amount,color and
consistency of
secretions.

-Provide
supplemental
humidification.
Increased fluid intake.



-Changes in
respirations, use of
accessory muscles
and presence of
adventitious breath
sounds suggest
retention of
secretions.

-Facilitates drainage
of secretion, work of
breathing and lung
expansion.

-Prevents pooling of
oral secretions,
reducing risk for
aspiration.



-Prevents secretion
from obstructing
airway.



-Supplemental
humidification
decreases mucous
crusting and
facilitates on

14


-No lesions noted.

-No tenderness when
palpated.

-Decreased chest
expansion observed
and there is an
increased tactile
fremitus.

-Upon auscultation,
crackles and
wheezes heard.

-Productive cough
and used of
accessory breathing
muscles.

-Barrel chest.

-There is minimal
flaring of nares.

-Cool and clammy
skin.

-Pale skin color,
buccal mucosa and
conjunctiva.

-3 seconds delayed
capillary refill test.




-Resume oral intake
with caution.




expectoration or
suctioning.

-Changes in muscle
strength and nerve
innervations increase
likelihood of
aspiration.


15

-Slight clubbing of
finger nails.

-Weakness.

-Fatigue.

-Lethargic. GCS of
11.

Laboratory:

-Decreased
hemoglobin(11.1 g/dl)

-Decreased
hematocrit (0.33)

-Decreased
lymphocytes (18%)

-Increased
Segmenters(82%)

-(+) PTB on chest x-
ray

-Decreased
potassium
(2.97 mmol/L)

-Compensated
Respiratory Acidosis
(pCO2 53.2 mmHg
and p02 165.5 mmHg
; pH 7.385)
16