Assesment Nursing Diagnosis (1) Ineffective Airway Clearance related to thick sputum, secondary to pneumonia .

Planning Expected outcome Nursing Interventions Rationale

Respiratory Status: Airway [0410] evidenced by not compromised Respiratory rate Moves sputum out of airway No adventitious breath sounds Patency as

Assist her to a sitting position with head slightly flexed, shoulders relaxed, and knees flexed.

Lying flat causes the abdominal organs to shift toward the chest, crowding the lungs and making it more difficult to breathe.

Encourage her to take several deep breaths. Encourage her to take a deep breath, hold for 2 seconds, and cough two or three times in

Deep

breathing before

promotes controlled

oxygenation coughing. Controlled

(as evidenced by rapid respirations, diminished and adventitious breath sounds, thick yellow sputum)

coughing

is

accomplished by closure of the glottis and the explosive

succession. Encourage use of

expulsion of air from the lungs by the work of abdominal and chest muscles. Breathing exercises help

incentive spirometry, as appropriate. Promote systemic fluid hydration, as appropriate. Monitor depth, rate, and rhythm, effort of

maximize ventilation. Adequate fluid intake enhances liquefaction secretions of and pulmonary facilitates

respirations.
1

expectoration of mucus

Note

chest

movement,

Provides a basis for evaluating adequacy of ventilation. Presence of nasal flaring and use of accessory may to muscles occur of in

watching for symmetry, use of accessory muscles, supraclavicular intercostal retractions. Auscultate breath and and muscle

respirations response ventilation.

ineffective

As fluid and mucus accumulate, abnormal breath sounds can be heard including crackles and

sounds, noting areas of decreased or absent

ventilation and presence of adventitious sounds. Auscultate lung sounds after treatments to note results. Monitor clients ability to cough effectively. Monitor clients

diminished breath sounds owing to fluid-filled air spaces and diminished lung volume. Assists in evaluating prescribed treatments and client outcomes. Respiratory tract infections alter the amount and character of secretions. An ineffective cough compromises airway clearance and prevents mucus from being expelled.

respiratory secretions. Institute respiratory

therapy treatments (e.g., nebulizer) as needed.

2

Monitor

for

increased anxiety,

People

with

pneumonia

restlessness, and air hunger. Note

commonly produce rust-colored, purulent sputum.

changes

in

A variety of respiratory therapy treatments may be used to open constricted airways and liquefy secretions. These clinical manifestations

SpO2,tidal volume, and changes in arterial blood gas values, as

appropriate

would be early indicators of hypoxia. Evaluates oxygenation, the status of and

ventilation,

acidbase balance.

Evaluation : 24 September 2011 Outcome partially met. Mdm Noriah coughs and deep breathes purposefully q12h during the day. Her fluid intake is approximately 1,500 mL each day. Cough continues to be productive of moderately thick, rusty-colored sputum. Inspiratory crackles remain present in right lower lobe. *The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or intervention.
Outcomes, interventions and activities selected are only a sample of those by NOC and NIC and should be further individualized for each client

Assesment Nursing Diagnosis (2) Problem : Risk for aspiration

Planning Expected outcome Nursing Interventions Rationale Signs of aspiration should be detected as soon as possible to prevent further aspiration and to initiate treatment that can be Auscultate frequently. lung sounds lifesaving (Ackley & Ladwig,

Long Term:

Monitor

respiratory

rate,

depth, and effort. Pt will maintain a

Pt

daughter

states patent airway and

that her mother has clear lung sounds been struggling with by discharge. swallowing and seems to choke a lot since Short Term: her stroke. Pt will swallow and Objective : Diagnosis and of digest NG tube

2008, p. 149). Bronchial auscultation of lung sounds was shown to be specific in identifying clients at risk for aspiration (Ackley & Ladwig, 2008, p. 149).

Measure and record the length of the tube that is outside defined of the body to at

interval

help

stroke medications and ice sided chips PO without aspiration throughout shift, by 1900. this

ensure correct placement.

right

hemiperisis

Pt

exhibits

difficulty without

As part of maintaining correct placement, it is helpful to note the length of the tube outside of the body; it is possible for a tube to

swallowing choking.

Orders speech consult

to

have

slide

out

and

be

in

the

therapy

esophagus,

without

obvious

disruption of the tape (Ackley & Ladwig, 2008, p. 149).

Evaluation : 24 September 2011 Refer speech therapy patient not safe for swallowing to continue NG tube feeding.

Assesment Nursing Diagnosis (3) Ineffective breathing pattern

Planning Expected outcome Nursing Interventions Rationale

Maintain normal pulmonary function.

Do any of the factors identified study Noriah in the case Mdm acute

Assess

knowledge

and

understanding of pneumonia and its effects. Assist to develop a medication schedule that coordinates with

related to pleuritic chest pain Hyperthermia related inflammatory process Deficient knowledge about pneumonia and its treatment to

increase risk for

Describe measures to minimize elevations in body temperature. Identify a schedule for taking her medication that will facilitate

bacterial pneumonia? Mdm. Noriah WBC showed

normal daily routine.

differential

increased neutrophil and band counts. Describe

Teach about the following: 1. Importance of avoiding use of a cough suppressant except night to facilitate rest 2. Ways to increase fluid intake to reduce fever and maintain thin mucus for easy expectoration 3. Beneficial effects of rest, at

the reason for and effect of this change. Even though Mdm Noriah has no history of

medication anaphylactic

allergies, shock

compliance with the regimen

remains a potential risk. Describe the sequence of

6

especially during the acute phase of her illness

events

leading shock,

to its and

4. Safe

use

of

aspirin

and

anaphylactic initial

acetaminophen to reduce feve 5. Importance of taking all

symptoms,

immediate interventions. Had Mdm

nursing

prescribed medication doses as scheduled

Noriah

6. Signs

of

complications or

of

required hospitalization to treat her acute interruption

pneumonia

worsening

pneumonia to report

pneumonia,

of her usual activities and responsibilities could lead to anxiety. Develop a care plan for using this the

situation, nursing

diagnosis,

Altered role performance related to hospitalization.

EVALUATION : 26 September 2011

The sputum culture confirms S. pneumoniae as the cause of Mdm Noriah pneumonia. When she returns for her follow-up appointment, she reports that she began to feel better after 2 days on antibiotic .Her examination reveals good breath sounds throughout with no adventitious sounds. The follow-up sputum culture is free of pathogens 7

Assesment Nursing Diagnosis (4) Impaired mobility

Planning Expected outcome Nursing Interventions Rationale

physical She will maintain or improve position functional of joints

Assess functional ability and level of tolerance in perfoming activity, factors that lead to pain

To detect problems and help to establish appropriate plan for care

Related

to

reduce within limitation of will archive joint and will

Help to determine presence of deficit Help detect problem in particular joint and as baseline for

ability to bear weight illness process. limb length, and poor gait and balance, She

discomfort. Assess client degree of cognitive ability to follow commands with the and adapt

presented marked impairment.

with optimal cognitive mobility free

appropriate intervention Correct body alignment, good posture allow balance weight to

intervention

from

flexion

needed Assess range of joint

contracture

both joints hence assist in reduce pain and increase mobility level Adequate energy reserved gain from balance sleep and rest pattern increase tolerance in

motion and note for joint swelling, tenderness,

structure and functional abnormalities. Instruct maintain alignment, caregiver proper good to body body

activities. Family gain to understanding and cooperating intervention. in the exercise

posture and correct and

8

balance the use of joints or leg while mobilizing the client. Teach caregiver correct methods of transferring from lateral lying to sitting, turning,

transferring from bed to wheel chair

Evaluation : 27 September 2011 Client had slightly improved her gait and stability to weight bearing but still need to retrain. She was able to maintain good functional position at high fowlers position while sitting on the chair, rather than to bear weight and changing position gradually.