Far Eastern University

Institute of Nursing
VALINO, Hyacinth G.
BSN110 Group 39

Diagnosis of Patient: Community Acquired Pneumonia

Nursing
GOALS and
Diagnosis/Cu ANALYSIS INTERVENTIONS RATIONALE EVALUATION
OBJECTIVES
es

Ineffective Situational Goal: After 5 hrs After 5 hours of

airway Analysis: of nursing nursing intervention,
clearance Ineffective intervention,the the client able to
related to airways client will be able have an improved
retained clearance to have airway as evidenced
secretions occurs due to improved airway by,
and the retained clearance.
inflammatio secretions in INDEPENDENT: a. signs of relief
n of the the airway OBJECTIVES: 1. Assist client in Positioning helps
airway which is After nursing 5 semi-fowler’s Maximize lung b. lowered if not
secondary to primarily hours of nursing position. expansion. normal breathing
pneumonia caused by the intervention the pattern.
as evidenced production of client will be able 2. Change To take advantage
by: sputum that it to: position every 2 of gravity c. no difficulty
is not hours decreasing breathing.
Subjective expectorated a. show signs of pressure on the
Cues: which is relief diaphragm and d. secretions
-“hirap nga resulted from enhance expectorated.
siya infection and b. have lowered ventilation to
huminga…” as body weakness if not normal different lung e. behaviors to
verbalized by due to illness. breathing segments. improve or maintain
the relative. pattern 3. Encourage deep airway are
 Health breathing exercise Helps mobilize demonstrated.
-he added, Implication: c. will report no and coughing secretion.
“may plema Virus may difficulty in exercise
pati kapag enter the body breathing.
umuubo siya.” through the 4. Encourage to Hydration helps
respiratory d. expectorate increase fluid thin secretions.
Objective tract which secretions. intake to at least 2
Cues: initially causes L a day.
> presence of some minor e. demonstrate Chest
crackles upon upper behaviors to 5. Perform chest Physiotherapy
auscultation respiratory improve or physiotherapy, if techniques use
symptoms maintain airway. needed, and also forces of gravity
> Productive such as instruct client’s and motion to
cough respiratory significant others facilitate secretion
infections and in this techniques. removal.
> Appears this lead to the
weak production of 6. Encourage
respiratory opportunities for Prevents fatigue.
>Difficulty in secretions. rest.
speakig. Sputum
production is 7. Keep client clam Stressors may
>Restlessness one way of the and relax. compromise
body to protect airway and
Measuremen itself from additional
t: infection but if movement may
RR: 38 cpm not expelled DEPENDENT cause further
may lead to 2.1. Provide fatigue.
poor gas supplemental
exchange that humidification via Nebulization helps
causes fatigue use of nebulizer. in
or cyanosis. liquefying
secretions for
(Source: 2.5. Administer better and faster
Fundamentals medication as expectorating the
of Nursing,5th ordered. secretions.
ed. by Taylor
pg. 1395) Medications help
COLLABORATIVE: in expectoration
1.Instruct and w/c relieves
encouragfe congestion of the
relative to do airway.
Chest
Physiotherapy. Chest
Physiotherapy
techniques use
3. Encourage forces of gravity
relative to and motion to
provide nasal facilitate secretion
care to the removal
client.
Helps remove dry
accumulated
mucus in the
nostrils.

(Sources: NANDA
pg. 77-79,
Fundamentals of
Nursing,5th ed. by
Taylor pg. 1032)