ASSESSMENT

Subjective:Agsak it toy barukong ko aglalo noh aguyek nak as verbalized by patient. Objective: Use of accessory muscle Dyspnea Fatigue. V/S taken asfollows: T: 36.4 C P:74 bpm R:24

DIAGNOSIS
Acute pain r/tlocalizedinflam mation andpersistent cough

INFERENCE
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),a nd pneumonia in an immune compromisedperson.Ca usesincludebacteria(Str eptococcus,Staphylococ cus, Haemophilus influenza ,Klebsiella,Legionella).C ommunityAcquiredPneu monia(CAD) is Adisease inwhichindividualswho have notrecently beenhospitalizeddevelo p aninfection of thelungs. It is anacuteinflammatoryco

PLANNING
After 8 hoursof nursinginterventions, the patientwill : Displaypatent airway withbreathso unds clearing and absence of dyspnea

INTERVENTION
Independent: Elevate head ofthe bed, changepositionfrequent ly. Assist patientwith deepbreathingexercises. Demonstrate orhelp patientlearn to performactivity likesplinting chestand effectivecoughing whilein uprightposition. Force fluids to atleast 3000 mlper day and offerwarm, ratherthan cold fluids. Collaborative: Administermedications asprescribe:mucolytic orexpectorants. Provide supplementalfluids.

RATIONALE
Lowersdiaphragm, promotingchestexpa nsionandexpectorati onof secretions. Deepbreathingfacili tatesmaximumexpa nsion ofthe lungs andsmallerairways. Coughing is a natural self cleaning mechanism. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort. Fluidsespeciallywar m liquidsaid inmobilizationandex pectorationof secretions. Aids inreduction ofbronchospasm andmobilization ofsecretions. Fluids arerequired toreplace lossesand

EVALUATION
After 8hours of nursing interventions, the patient was able to display patent airway with breath sounds clearing and absence of dyspnea.

nditionthats resultfrom aspiration of oropharyngeal secretions orstomachcontents in thelungs

aid inmobilization ofsecretions.

Assessment Subjective: Marigatan nak nga umanges ading As verbalized by the patient Objective: Abnormal breath sounds: wet crackles on (R) and(L) lung bases. Dyspnea; use of accessory muscles for respiration: elevated shoulders. Increase in respiratory rate: RR-24cpm

NursingDiagnosis

Planning

Intervention Assess respiratory function, e.g., breath sounds, rate, and use of accessory muscles and secretion characteristics and amount.

Rationale

Evaluation At the end of the shift, theclient wasable todisplaypatency of airway asmanifestedby: Clients respiratory rate is within normal range RR18 bpm. Secretions decreased in amount from 40 cc to 30 cc collected in an 8-hr. shift(Continue assessment of respiratory status and suctioning as needed). Clientsrestless ness was alleviated Andremainedcalm.

Ineffectiveairwaycle Following an8-hr arancerelated nursingintervention,the toincreasedproduct client willbe able to: ion of Sustainrespiratoryra bronchialsecretions te withinnormalrange: RR-12-20cpm. Displaydecreasing amount of secretions(less than40cc). Allayrestless-ness.

Provides abasis forevaluatingadequacyof ventilation. Use of accessorymuscles of respirationmay occurinresponsetoineffectiv eventilation. Positionpatient insemi- Cracklesindicate orhigh-Fowlersposition. accumulation of Assessairwaypatency. secretionsandinability Suction as needed toclearairways. when patient is Expectorations experiencing difficulty maybedifferentwhensecreti of breathing, limiting onsare verythick. duration of suction to15 Positioninghelpsmaximizel sec orless. ungexpansion. Administermedications asindicated:Bronchodila Tomaintainadequateairwayp tors. atency. Duration should be limited to reduce hazard of hypoxia, damage airway mucosa and impair cilia action. Increases lumen size of the trachea bronchial tree, thus decreasing resistance to air flow and improving oxygen delivery.