NURSING DIAGNOSIS: Impaired Gas Exchange r/t decreased functional lung tissue

DEFINING SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION

CHARACTERISTICS BASIS INTERVENTION
SUBJECTIVE: An infection Short Term: Safe and Quality
“Usahay triggers alveolar After 8 hours of Nursing Care After 3 days of
maghangak na siya inflammation and nursing nursing
tungod sa iyang edema. This interventions, the 1. Assess - Manifestation of interventions, the
ubo unya naa produces an area patient’s SO will be respiratory rate, respiratory patient was able
pasad jod plema of low ventilation able to demonstrate depth and ease. distress is to maintain clear
nga dili niya with normal techniques to dependent on lung fields and
magawas” stated perfusion. improved indicative of the remain free of
by the mother. Capillaries ventilation. degree of lung signs of
become involvement and respiratory
engorged with underlying distress
OBJECTIVE: blood, causing Long Term: general status.
 With O2 stasis. As the After 3 days of
inhalation alveolocapillary nursing
attached via nasal membrane interventions, the 2. Monitor patient - High fever
cannula @ 2L/min breaks down, patient will be able body temperature greatly increases
 Productive cough alveoli fill with to maintain clear metabolic
noted blood and lung fields and demands and
 Irritability exudates remain free of signs oxygen
 Nasal flaring resulting in of respiratory consumption and
 Restlessness atelectasis. distress. alters cellular
 Fast breathing Shrunken alveoli oxygenation.
noted can’t accomplish
 RR – 53 cpm gas exchange. 3. Keep patient in a - Promotes lung
 O2 sat – 99% moderate high back expansion and
rest decrease
(Brunner and respiratory
Suddarth’s Medical efforts
Surgical Nursing
12th Edition) 4. Limit visitors as - Reduces
indicated. likelihood of
exposure to
other infectious
pathogens.

5. Suction as - Stimulates
needed cough or
mechanically
clears airway in
patient who is
unable to cough
effectively.

6. Assist with - Facilitates

nebulizer liquefaction and
treatments removal of
secretions.

Collaborative and
Teamwork

1. Administer - These drugs

antimicrobials as are used to
prescribed combat most of
the microbial
pneumonias
NURSING DIAGNOSIS: Ineffective Airway Clearance r/t retained mucous secretion

DEFINING SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION

CHARACTERISTICS BASIS INTERVENTION
SUBJECTIVE: Bacteria are Short Term: Safe and Quality After 3 days of
“Usahay invading the lung After 8 hours of Nursing Care nursing
maghangak na siya parenchyma thus nursing intervention,
tungod sa iyang producing interventions, the 1. Assess the rate, - Tachypnea, the patient was
ubo unya naa inflammatory patient will be rhythm, and depth shallow able to maintain
pasad jod plema process, and able to maintain of respiration, chest respirations and patent airway
nga dili niya these responses patent airway and movement, and use asymmetric chest and lung sound
magawas” stated leading to filling clear breath of accessory movement are is clear.
by the mother. of the alveolar sounds. muscles. frequently present
sacs with because of
exudates leading discomfort of
to consolidation. moving chest wall
OBJECTIVE: The airway is and/or fluid in lung
 Productive cough narrowed thus Long Term:
noted but unable wheezes is being After 3 days of 2. Auscultate lung - Decreased
to expectorate heard. nursing fields, noting areas airflow occurs in
 Wheeze heard interventions, the of decreased or areas with
noted on both patient will be absent airflow and consolidated fluid.
lower lungs able to maintain adventitious breath Bronchial breath
 RR – 53 cpm patent airway with sounds: crackles, sounds can also
 O2 sat – 99% breath sounds wheezes. occur in these
clearing, absence consolidated
(Brunner and of dyspnea, and areas.
Suddarth’s Medical effectively clearing 3. Assess the
Surgical Nursing secretions. patient’s hydration
12th Edition) status - Airway clearance
is hindered with
inadequate
hydration and
 thickening of
secretions.
4. Put the patient in
Moderate High
Back Rest position. - Promotes lung
expansion and
decrease
5. Encourage chest respiratory efforts
tapping and
burping after - To avoid
feeding aspiration and to
assist in
maintaining a
patent airway
6. Encourage fluid
intake - Maintain
hydration and
increases ciliary
action to remove
secretions and
reduces the
viscosity of
secretions
Collaborative and
Teamwork

1. Assist in
nebulizing - to facilitates
liquefaction and
expectoration of
secretions
NURSING DIAGNOSIS: Ineffective Breathing Pattern r/t decreased lung volume capacity as evidenced by tachypnea and
presence of wheeze on both lung fields

DEFINING SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION

CHARACTERISTICS BASIS INTERVENTION
SUBJECTIVE: It occurs when Short Term: Safe and Quality After 3 days of
“Usahay inspiration and After 8 hours of Nursing Care nursing
maghangak na siya expiration does nursing intervention,
tungod sa iyang not provide interventions, the 1. Assess the rate, - Tachypnea, the patient
ubo unya naa adequate patient will be rhythm, and depth shallow established a
pasad jod plema ventilation. able to maintain of respiration, chest respirations and normal or
nga dili niya Pleural an effective movement, and use asymmetric chest effective
magawas” stated inflammation breathing pattern of accessory movement are breathing
by the mother. causes sharp as evidenced by muscles. frequently present pattern and free
localized pain relaxed breathing because of from respiratory
that increases at normal rate and discomfort of distress.
deep breathing, depth. moving chest wall
OBJECTIVE: coughing, and and/or fluid in lung
 Productive cough movement. This
noted but unable can result to 2. Auscultate lung - Decreased
to expectorate shallow and rapid fields, noting areas airflow occurs in
secretions breathing Long Term: of decreased or areas with
 Wheeze heard pattern. Distal After 3 days of absent airflow and consolidated fluid.
noted on both airway and alveoli nursing adventitious breath Bronchial breath
lower lungs may no expand interventions, the sounds: crackles, sounds can also
 With O2 optimally with patient will be wheezes. occur in these
inhalation each breath, able to establish consolidated
attached via increasing the normal breathing areas.
nasal cannula @ possibility of pattern. 3. Put the patient in
2L/min atelectasis Moderate High
 Fast breathing Back Rest position. - Promotes lung
 noted expansion and
 RR – 53 cpm (Brunner and decrease
 O2 sat – 99% Suddarth’s Medical 4. Encourage chest respiratory efforts
Surgical Nursing tapping and
12th Edition) burping after - To avoid
feeding aspiration and to
assist in
maintaining a
patent airway
5. Encourage fluid
intake - Maintain
hydration and
increases ciliary
action to remove
secretions and
reduces the
viscosity of
secretions
6. Monitored O2
inhalation @ - To provide
2L/min via nasal ventilation and
cannula oxygenation

Collaborative and
Teamwork

1. Assist in - to facilitates
nebulizing liquefaction and
expectoration of
secretions