Karen Elizabeth B.

Valdez
RLE 2
CUES AND CLUES NURSING
DIAGNOSIS
ANALYSIS GOAL AND
OBJECTIVES
IMPLEMENTATION RATIONALE EVALUATION
SUBJECTIVE
Meron akong plema
pero di ko mailabas
as verbalized

OBJECTIVE
RR=32
O2 Sat=97%
Difficulty of
breathing
Productive
cough of
yellow to
greenish
sputum for 4
days
Wheezed and
crackles on
both lung
fields
Difficulty
vocalizing
Uses
accessory
muscles upon
breathing
Labored
breathing
Ineffective
airway
clearance
related to
retained
secretions
secondary to
pneumonia
Pneumonia
bacteria are
invading lung
parenchyma thus,
producing
inflammatory
process. These
responses lead to
filling of the
alveolar sacs with
exudates leading
to consolidation.
The airway is
narrowed.
1. Maintain airway
patency
2. Expectorate
secretions
readily
3. Demonstrate
absence or
reduction of
congestion with
breath sounds
clear,
respiration
noiseless,
improved
oxygen
exchange.
4. Demonstrate
breathing
pattern with no
shortness of
breath and acute
distress
5. Practice deep
breathing and
coughing
exercises
1. Encourage to
increase fluid
intake




2. Position patient
in semi or high
fowlers








3. Encourage deep
breathing and
coughing
exercises


4. Advise to have
adequate rest
periods

5. Turn to sides at
regular interval


6. Administer
oxygen at 2-
3L/min as
ordered
1. Adequate
hydration
keeps
secretions
moist and
easier to
expectorate.
2. To take
advantage of
gravity
decreasing
pressure on the
diaphragm and
enhancing
drainage
of/ventilation
to different
lung segments
3. These
techniques
help
ventilation and
mobilize
secretions
4. Rest conserves
energy and
reduces degree
of dyspnea
5. To mobilize
and enhance
drainage of
secretion
6. This will
correct
impaired gas
exchange
After 7 hours of
nursing
intervention:
1. RR decreased
to 30

2. Patient still
unable to
expectorate
secretions

3. Patients O2
Sat increased to
99%