ASSESSMENT

Subjective:
Nahihirapan nga
siya huminga e
dahil sa sipon
niya, as
verbalized by the
mother.
Objective:
Thick sputum
Crackle breath
sounds
nasal flaring
Restlessness/
lethargic
Facial grimace
Fever (39.50C)

DIAGNOSIS
Ineffective
Airway
Clearance
related to
excessive
mucus,
secondary to
pneumonia
as evidenced
by crackles
breath
sound and
thick yellow
sputum

SCIENTIFIC
EXPLANATION
Bacterial
microorganism
enters the airway

transmission to the
alveoli

less function
(impaired gas
exchange)

mucus production
(inflammation of
bronchoiles and
alveoli)

Phagocyte
production

accumulation of
exudates
in alveoli

increase mucus
secretion

Ineffective airway
clearance

PLANNING
Discharge
Outcome:
After discharge,
the patient will be
able
to
demonstrate
absence
of
congestion
with
clear
breath
sounds,
and
improved
oxygen
exchange
as
evidenced by not
compromised
respiratory
rate,
moves sputum out
of airway and no
adventitious breath
sounds.

Short Term
Outcome:
After 2 hours of
nursing
interventions, the
mother will be able
to:
verbalize the
cause of
Reference:
breathing
Pathophysiology
pattern
by Thomas J. Nowak
disturbances in
& A. Gordon
relation to the
Handford
condition

IMPLEMENTATION

RATIONALE

INDEPENDENT:
a) Assess
a) Tachypnea,
rate/depth of
shallow
respirations and
respirations, and
chest movement.
asymmetric chest
b) Auscultate lung
movement are
fields, noting
frequently
areas of
present because
decreased/absent
of discomfort of
airflow and
moving chest wall
adventitious
and/or fluid in
breath sounds
lung.
like crackles or
b) Decreased airflow
wheezes.
occurs in areas
c) Teach and assist
consolidated with
mother to
fluid. Bronchial
elevate head of
breath sounds
bed and change
(normal over
patients position
bronchus) can
appropriate for
also occur in
age and
consolidated
condition every 2
areas. Crackles,
hours.
rhonchi, and
d) Instruct and
wheezes are
assist mother to
heard on
initiate patient
inspiration and/or
with frequent
expiration in
deep-breathing
response to fluid
exercises.
accumulation,
e) Teach and assist
thick secretions,
mother how to
and airway
perform activity
spasm/obstructio
such as splinting
n.
chest and
c) Lowers
effective
diaphragm,

EVALUATION
OUTCOME
ACHIEVED.
Discharge
Outcome:
After
discharge,
the patient
demonstrate
absence of
congestion with
clear breath
sounds and
improved
oxygen
exchange as
evidenced by
decreased
temperature
within normal
range,
acyanosis,
alertness,
regular sleep
pattern, normal
breath sounds.
Short Term
Outcome:
After 2 hours of
nursing
interventions,
the mother:
verbalized the
cause of

CHAPTER 18

understand and
coughing while in
promoting chest
breathing
upright position.
expansion,
pattern
state ways to
f)
Promote
systemic
aeration
of
lung
disturbances
improve
fluid hydration,
segments,
in relation to
breathing
as
appropriate.
mobilization
and
the patients
pattern.
g) Provide mother
expectoration of
condition such
the information
secretions.
as productive
about the
d) Deep breathing
cough,
necessity of
facilitates
understood
raising and
maximum
and state
expectorating
expansion of the
ways to
secretions versus e) lungs/smaller
improved
swallowing them
airways.
breathing
h) Monitor clients
Coughing is a
pattern such
ability to cough
natural selfas performing
effectively.
cleaning
deepi) Monitor for
mechanism,
breathing
increased
assisting the cilia
pattern and
restlessness,
to maintain
splinting or
anxiety, and air
patent airways.
back tapping.
hunger.
f) Splinting reduces
chest discomfort,
COLLABORATIVE:
and an upright
j) Assist
position favors
with/monitor
deeper, more
effects
forceful cough
of nebulizer
effort.
treatments and
g) Fluids (especially
other respiratory
warm liquids) aid
physiotherapy.
in mobilization
Perform
and
treatments
expectoration of
between meals
secretions
and limit fluids
h) To report changes
when
in color and the
appropriate.
amount in the
k) Administer
event that

medications as
indicated:
mucolytics,
expectorants,
bronchodilators,
analgesics.
l) Provide
supplemental
fluids, e.g., IV,
humidified
oxygen, and
room
humidification.

medical
interventions may
be needed to
prevent/ treat
infection.
i) Respiratory tract
infections alter
the amount and
character of
secretions. An
ineffective cough
compromises
airway clearance
and prevents
mucus from being
expelled.
j) These clinical
manifestations
would be early
indicators of
hypoxia.
k) Facilitates
liquefaction and
removal of
secretions.
Postural drainage
may not be
effective in
interstitial
pneumonias or
those causing
alveolar
exudate/destructi
on. Coordination
of
treatments/sched
ules and oral

intake reduces
likelihood
of vomiting with
coughing,
expectorations.
l) Aids in reduction
of bronchospasm
and mobilization
of secretions and
improves
coughing effort.
m) Fluids are
required to
replace losses
(including
insensible) and
aid in
mobilization of
secretions.
n) Note: Some
studies indicate
that room
humidification
has been found to
provide minimal
benefit and is
thought to
increase the risk
of transmitting
infection.