ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

OBJECTIVE Ineffective airway ST -Established Rapport -For the client to

clearance related to After 3 hours of nursing participate and give
-Warm to touch increased production of intervention, accurate information.
-Tachypnea secretions and The client will maintain - Elevated head of bed, - Doing so would lower
-Tachycardic increased viscosity airway patency change position the diaphragm and
-Use of accessory frequently. promote chest
muscles expansion, aeration of
-Intercostal retractions LT lung segments,
and pleuritic chestpain mobilization and
-Unilateral decrease After the shift, expectoration of
respiratory expansion The client will secretions.
-Increased tactile demonstrate - Teach and assist - Deep breathing
fremitus absence/reduction of patient with proper exercises facilitates
-Dullness to percussion congestion with breath deep-breathing maximum expansion of
-Bronchial breath sounding clear, exercises. Demonstrate the lungs and smaller
sounds noiseless respirations, proper splinting of chest airways, and improves
-Inspiratory crackles and improved oxygen and effective coughing the productivity of
-Pectoriloquy exchange while in upright cough.
-Egophony position. Encourage him Coughing is a reflex and
-Weight 72.9kgs to do so often. a natural self-cleaning
VS mechanism that assists
-BP 100/60 mmHg the cilia to maintain
-CR 115bpm patent airways. It is the
-RR 31 CPM most helpful way to
-Temp 38.6 remove most secretions.
-SpO2 89% Splinting reduces chest
discomfort and an
upright position favors
deeper and more
forceful cough effort
making it more effective
- Suction as indicated: - Stimulates cough or
frequent coughing, mechanically clears
adventitious breath airway in patient who is
sounds, desaturation unable to do so because
related to airway of ineffective cough or
secretions. decreased level of
consciousness. Note:
 Suctioning can cause
increased hypoxemia;
hyper oxygenate before,
during, and after
suctioning.
- Maintain adequate - Fluids, especially warm
hydration by forcing liquids, aid in
fluids to at least 3000 mobilization and
mL/day unless expectoration of
contraindicated. Offer secretions. Fluids help
warm, rather than cold, maintain hydration and
fluids. increases ciliary action
to remove secretions
and reduces the
viscosity of secretions.
Thinner secretions are
easier to cough out.
- Assist and monitor - Nebulizers humidify
effects of nebulizer the airway to thin
treatment and other secretions and facilitates
respiratory liquefaction and
physiotherapy: incentive expectoration of
spirometer, IPPB, secretions.
percussion, postural Postural drainage may
drainage. not be as effective in
Perform treatments interstitial pneumonias
between meals and limit or those causing
fluids when appropriate. alveolar exudate or
destruction.
Incentive
spirometry serves to
improve deep breathing
and helps prevent
atelectasis.
Chest percussion helps
loosen and mobilize
secretions in smaller
airways that cannot be
removed by coughing or
 suctioning.
Coordination of
treatments and oral
intake reduces
likelihood of vomiting
with coughing,
- Encourage ambulation. expectorations.
- Helps mobilize
secretions and reduces
- Administer atelectasis.
medications as indicated

- Use humidified oxygen

or humidifier at bedside. - Increasing the
humidity will decrease
the viscosity of
secretions. Clean the
humidifier before use
to avoid bacterial
growth.
- Monitor serial chest x-
rays, ABGs, pulse - Follows progress and
oximetry readings. effects and extent of
pneumonia. Therapeutic
regimen, and may
facilitate necessary
alterations in therapy.
Oxygen saturation
should be maintain at
90% or greater.
Imbalances in PaCO2
and PaO2 may indicate
respiratory fatigue.
- Anticipate the need for
supplemental oxygen or - These measures are
intubation if patient’s needed to correct
condition deteriorates. hypoxemia. Intubation is
needed for deep
suctioning efforts and
provide a source for
 augmenting
oxygenation.
-

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

OBJECTIVE Impaired Gas exchange ST -Established Rapport -For the client to
related to Inflammation After 3 hours of nursing participate and give
-Warm to touch of airways and alveoli intervention, accurate information.
-Tachypnea The client will - Maintain bedrest by - Prevents over
-Tachycardic demonstrate improved planning activity and exhaustion and reduces
-Use of accessory ventilation and rest periods to minimize oxygen demands to
muscles adequate oxygenation energy use. Encourage facilitate resolution of
-Intercostal retractions of tissues by ABGs use infection. Relaxation
and pleuritic chestpain within client’s usual of relaxation techniques techniques helps
-Unilateral decrease parameters and absence and diversional conserve energy that
respiratory expansion of symptoms of activities. can be used for effective
-Increased tactile respiratory distress breathing and coughing
fremitus efforts.
-Dullness to percussion - Elevate head and - These measures
-Bronchial breath LT encourage frequent promote maximum
sounds position changes, deep chest expansion,
-Inspiratory crackles After the shift, breathing, and effective mobilize secretions and
-Pectoriloquy The client will coughing. improve ventilation.
-Egophony participate in treatment
-Weight 72.9kgs regimen within level of - Administer oxygen - The purpose of oxygen
VS ability or situation therapy by appropriate therapy is to maintain
-BP 100/60 mmHg means: nasal prongs, PaO2 above 60 mmHg.
-CR 115bpm mask, Venturi mask. Oxygen is administered
-RR 31 CPM by the method that
-Temp 38.6 provides appropriate
-SpO2 89% delivery within the
patient’s tolerance.
Note: Patients with
underlying chronic lung
diseases should be given
oxygen cautiously.

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

OBJECTIVE Ineffective breathing ST -Established Rapport -For the client to
pattern related to After 3 hours of nursing participate and give
-Warm to touch Decreased lung intervention, accurate information.
-Tachypnea expansion aeb using The client will - Place patient with - A sitting position
-Tachycardic accessory muscle established a normal, proper body alignment permits maximum lung
-Use of accessory effective respiratory. for maximum breathing excursion and chest
muscles pattern. expansion.
-Intercostal retractions - Encourage sustained - These techniques
and pleuritic chestpain LT deep breaths by: promotes deep
-Unilateral decrease Using demonstration: inspiration, which
respiratory expansion After the shift, highlighting slow increases oxygenation
-Increased tactile The client will initiate inhalation, holding end and prevents
fremitus needed lifestyle changes inspiration for a few atelectasis. Controlled
-Dullness to percussion seconds, and passive breathing methods may
-Bronchial breath exhalation also aid slow
sounds Utilizing incentive respirations in patients
-Inspiratory crackles spirometer who are tachypneic.
-Pectoriloquy Requiring the patient to Prolonged expiration
-Egophony yawn prevents air trapping.
-Weight 72.9kgs - Encourage - This method relaxes
VS diaphragmatic breathing muscles and increases
-BP 100/60 mmHg for patients with chronic the patient’s oxygen
-CR 115bpm disease. level.
-RR 31 CPM - Maintain a clear airway - This facilitates
-Temp 38.6 by encouraging patient adequate clearance of
-SpO2 89% to mobilize own secretions.
secretions with
successful coughing.
- Suction secretions, as - This is to clear
necessary. blockage in airway.
- Stay with the patient - This will reduce the
during acute episodes of patient’s anxiety,
respiratory distress. thereby reducing
oxygen demand.
- Ambulate patient as - Ambulation can further
tolerated with doctor’s break up and move
order three times daily. secretions that block the
- Encourage frequent airways.
rest periods and teach - Extra activity can
patient to pace activity. worsen shortness of
 breath. Ensure the
patient rests between
- Encourage small strenuous activities.
frequent meals. - This prevents crowding
- Help patient with of the diaphragm
ADLs, as necessary - This conserves energy
and avoids overexertion
- Educate patient or and fatigue.
significant other proper - These allow sufficient
breathing, coughing, mobilization of
and splinting methods. secretions.
- Teach patient about:
pursed-lip breathing - These measures allow
abdominal breathing patient to participate in
performing relaxation maintaining health
techniques status and improve
performing relaxation ventilation.
techniques
taking prescribed
medications (ensuring
accuracy of dose and
frequency and
monitoring adverse
effects)
scheduling activities to
avoid fatigue and
provide for rest periods