NURSING DIAGNOSIS Subjective: Impaired gas Inuubo ako at exchange nahihirapan related to akong inflammatory makahinga.

process in the lung parenchyma Mas and alveoli as nakakahinga ako ng maayos manifested by kapag ganitong restlessness. may Oxygen. Kapag wala, ang hirap talaga huminga at saka matanda na rin ako. Objective: Restlessness Nasal flaring Crackles heard upon auscultation on both lung filed Oxygen via nasal cannula

CUES

ANALYSIS

Communityacquired pneumo nia (CAP) is a disease in which individuals who have not recently been hospitalized develop an infection of the lungs (pneum Objectives: onia). Independent CAP is a common 1. After 30 minutes illness and can of intervention, the affect people of client would be able all ages. CAP to have normal often causes breath respiration problems like and breath sounds difficulty in within 20 minutes. breathing, fever, chest pains, and a cough. CAP occurs because the areas of the lung which 2. After 30 minutes absorb oxygen of nursing (alveoli) from the intervention, the client would be able atmosphere become filled to have easier with fluid and breathing. cannot work

GOALS and OBJECTIVES Goal: After 8 hours of nursing intervention, the client will be able to establish a normal and effective respiratory pattern.

NURSING INTERVENTION

RATIONALE

EVALUATION After 8 hours of nursing intervention, the client was able to establish a normal and effective respiratory pattern.

Independent 1.Monitor respiration breath sounds

Tachypnea, stridor, and crackles or wheezes are indicative to repiratory distress and/or accumulation of fluid (Nurse's Pocket Guide by Doenges et al pp.78)

2. Place the client in Positioning the high fowler s client in high position. fowler's position promote lung expansion. (Fundamentals of Nursing by Kozier

effectively Pneumonia also is the inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, chlamydiae, mycoplasma, fungi, parasites and viruses. As the lung parenchyma and alveoli of the lungs are inflamed it impairs gas exchange due to the alterations in the alveoli which is the site for actual gas exchange.

pp.789)

3. After 45 minutes 3.1 Increased fluid Hydration can help of nursing intake. liquefy viscous intervention, the secretions and client would be able improve secretion to mobilize clearance. secretions. (Nurse's Pocket Guide Doenges.79)

3.2Encourage frequent position changes and deep breathing/coughing exercises.

Promotes optimal chest expansion and drainage of secretions.

3.3 Suctioning

Suction is used to clear airway when excessive or viscous secretions are blocking the airway or client is unable to cough effectively. (Nurse's Pocket Guide by Doenges et al pp.78)

3.4 Perform Chest Physiotherapy.

Chest Physiotherapy

is

used to mechanically dislodge tenacious secretions from the bronchial walls. (Nursing Care Management Skill Manual pp.60)

Dependent: 4. After 15 minutes of nursing intervention, the client would be able to take the medications and treatment prescribed by the physician within the order time and date of administration.

Dependent: 4.1 Administer bronchodilators as ordered by the physician.

Bronchodilators are antiinflammtory drugs, excpectorants and cough suppressants that may treat respiratory problems. (Fundamentals of Nursing by Kozier pp.1369)

4.2 Perform oxygen therapy or administer oxygen by nasal cannula.

Administration of oxygen to client to prevent or relieve hypoxia. (Nursing CareManagement Skill Manual pp.55)

Interdependent: 5. After 15 minutes 5.1 Instruct relatives of nursing to perform proper intervention, the nebulization client's relatives would be able to perform proper humidification and administer medication via nebulization.

Nebulization is performed to deliver finer mist at a faster rate to moisten membrane. (Nursing CareManagement Skill Manual pp.69)