Patient: Bronchio del Pneumonia

Problem: Ineffective Airway Clearance

ASSESSMEN NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

T DIAGNOSI EXPLANATIO INTERVENTION OUTCOMES
S N S
Pneumonia is
an
S> Ø Ineffective Short Term: >Establish >To gain the Short Term:
inflammation
airway rapport to trust and
of the lung
clearance patient and SO cooperation
parenchyma,
O> Patient related to After 3-4 After 3-4
associated
manifested presence of hours of hours of
with alveolar
the ff: secretions nursing >To know nursing
edema and
secondary interventions and intervention
congestion >Assess
to , the determine s, the
that impair patient’s
- with pneumonia. patient’s patient’s patient’s
gas exchange. condition
unproductive respiration needs respiration
This
cough will improve shall have
accumulation
and difficulty improved
-with is an
of breathing >To and
wheezes and obstruction in
will be >Monitor and establish difficulty of
crackles the smooth
relieved. record V/S base line breathing
auscultated flowing of air
data shall have
on left lower in and out of
been
lungfield. the lungs.
Nursing Care Plan prepared by DaBrighterSide.com | Feel free to print this out or email it to your friends | DaBrighterSide © 2009 |
You may remove the header and the footer. Be sure to tell your friends about DaBrighterside.com! God Bless! Thanks to Kuya
Julius!!
 - presence of With this Long Term: >Auscultate >To identify relieved.
clear watery blockage a lung fields, areas of
discharge patent airway noting areas of consolidatio
from her is difficult to After 3 – 4 decreased/abse n and
nose maintain, this days of nt airflow and determine
Long Term:
results in nursing adventitious possible
decreased interventions breath sounds bronchospas
> Patient volume of , the patient m or
After 3 – 4
may manifest inspired air will maintain obstruction.
days of
the ff: resulting to an a patent >Assist patient
nursing
impaired airway. to change
- restlessness intervention
oxygen position every >To mobilize
s, the
- irritability exchange 30 minutes secretions
patient will
within the
have been
alveoli of the
able to
lungs. >Elevate head
maintain a
Resulting to a of bed and align
>To patent
lower oxygen head in the
facilitate airway.
supply for the middle
breathing
rest of the
body
>Provide health
teachings
regarding

Nursing Care Plan prepared by DaBrighterSide.com | Feel free to print this out or email it to your friends | DaBrighterSide © 2009 |
You may remove the header and the footer. Be sure to tell your friends about DaBrighterside.com! God Bless! Thanks to Kuya
Julius!!
 effective >To expel
coughing and the mucous
deep breathing
exercise.

>Encourage to
increase fluid
intake.

>Encourage
>To liquefy
steam
secretions
inhalation

>To moisten
secretions
>Administer and alleviate
meds as congestion
ordered

>To reduce

Nursing Care Plan prepared by DaBrighterSide.com | Feel free to print this out or email it to your friends | DaBrighterSide © 2009 |
You may remove the header and the footer. Be sure to tell your friends about DaBrighterside.com! God Bless! Thanks to Kuya
Julius!!
 bronchospas
m and
mobilize
secretion

Nursing Care Plan prepared by DaBrighterSide.com | Feel free to print this out or email it to your friends | DaBrighterSide © 2009 |
You may remove the header and the footer. Be sure to tell your friends about DaBrighterside.com! God Bless! Thanks to Kuya
Julius!!