C. NURSING PROBLEM PRIORITIZATION PRIORITIZATION DIAGNOSIS Problem No.

1 Ineffective Airway Clearance 1 JUSTIFICATION Airway must be given the first attention as based on the rule of ABC which is Airway, Breathing and Circulation. In addition, difficulty of breathing can cause anxiety to the client that is why, immediate attention must be done. Addressing the problem to proper health care provider will give patent airway to the client. Oxygenation is a vital need for every cell, if there are any problems related to it can easily affect the functioning of the individual. Retained secretions can cause blockage of airway which will further cause difficulty of breathing(Fundamentals of Nursing 8th ed by Kozier and erbs p. 1299
Lack of action in this health care problem may cause leading to hypoxia of the lung tissue and a significant ventilation-perfusion mismatch

Problem No. 2 Impaired Gas Exchange 2

Problem No. 3 Ineffective Breathing Pattern 3

This demands immediate treatment/care and subsequent medical attention, as they can result in ineffective breathing pattern. This also needs attention as based on the rule of ABC which is Airway, Breathing and Circulation. This is an actual problem that needs to address. Lack of action in this health care problem may cause dyspnea which may later cause a bigger threat to the health of the patient. Difficult and labored in breathing during which the individual has a persistent, unsatisfied need for air and feel distressed. (Fundamentals of Nursing 8th ed by Kozier and erbs p. 549) CAP is the inflammation of the lung parenchyma due to offending organisms, inflammatory lung response will be stimulated leading to

Problem No. 4 Hyperthermia

Problem No. 5 Activity Intolerance 5

the release of chemical mediators that would increase blood flow to the lung tissues leading to erythema, swelling, pain, and increased body temperature that would reset the hypothalamus which is the major center for regulation of body temperature The onset of pneumonia is generally marked by fever, dyspnea, and shortness of breath and easy fatigability that may lead to inability to perform activities of daily living

Problem No. 1 Ineffective Airway Clearance Assessment Nursing Diagnosis Scientific Explanation Planning Nursing Intervention Rationale Evaluation

Subjective Cue: nahihirapan siyang huminga dahil sa plema yun yung sinabi sa akin nung nars as verbalized by the mother.

Objective cues :

Ineffective Airway CommunityShort Term : > Assess respiratory Clearance related to Acquired status: breath retained secretions in Pneumonia is the sounds, respiratory the bronchi ( inflammation of the After 5 hours rate, oxygen increased thick lung parenchyma saturation, note of Nursing mucous secretions) when the offending Interventions, abnormalities such and lung organism reaches the patient will as dyspnea, presence inflammation the alveoli via of cyanosis, use of expectorate leading to droplets or saliva in accessory muscles, mucous as accumulation of whi8ch goblet cells flaring of nostrils evidenced by mucous in the produces an productive alveoli outpouring fluid into cough, the alveoli. The effective > Assess anxiety organisms multiply coughing and and reassure patient

> Abnormal breathing patterns may signal worsening of condition: flaring of nostrils indicate a significant decline in respiratory status: assessment establishes baseline and monitor response to interventions

Short Term :

The patient shall be able to expectorate mucous as evidenced by productive cough effective coughing and breathing exercise

>appears weak

>pale palpebral conjunctiva

> rales on both lung lobes upon chest auscultation

> difficulty of breathing

> shortness of breath

> non- productive cough

>Tachypnea

in the serous fluid and the infection is spread. The organisms damage the host by their overwhelming growth and interference with lung function leading to massive accumulation of mucus. Disruption of the mechanical defenses of cough and ciliary motility leads to the colonization of the lungs and accumulation of secretions in the alveoli and bronchi leading to ineffective airway clearance as evidence by nonproductive cough etc. alveolar exudates tend to consolidate,

breathing exercise

presence

Long Term : > Place patient in high fowlers position and support overbed table as needed.

> Being unstable to breath causes anxiety and fear: the patient needs a calming presence: anxiety increases the demand for oxygen

Long Term :

After 2 days of Nursing Interventions, the patient will maintain airway patency as evidenced by clear breath sounds, absence of dyspnea, etc.

> Maximize chest excursion and subsequent movement of air

> Encourage expectoration of secretions and assess the viscosity amount and color of secretions

The patient will maintain airway patency as evidenced by clear breath sounds, absence of dyspnea, etc.

> Thickened secretions of Cap re more likely to occlude the airway: making this observation would allow for implementation if measures to thin and loosen the secretions

>Restlessness

increasingly difficult to expectorate.

> Assist the patient coughing and deep breathing

> Mobilizes secretions and prevent atelectasis

> Orthopnea > Increase fluid intake

> Flaring of nostrils

> Assists with liquefying secretions and enhancing ability to clear airways

> Decrease demand for oxygen > Provide for periods of rest and activity, assisting devices as needed

> Elevate head of bed/ change of position every 2 hours

> To maintain an open airway and to take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of

secretions.

> Assist respiratory therapist the administration of nebulizer

>This causes bronchiodilation to ease breathing

> Establish intravenous access as ordered

> Ensures a route for rapid- acting medications

> Assess arterial blood gases (ABG)

>ABG provide data for treatment regarding the lungs ability to oxygenate tissues

> Provide humidified oxygen as ordered to maintain O2

> Loosen secretions, making them easier to expectorate coughing: improves oxygenation

saturation >90%

Problem No. 2 Impaired Gas Exchange Assessment Nursing Diagnosis Scientific Explanation Planning Nursing Intervention Rationale Evaluation

Subjective Cue: Pansin ko lagi siyang parang hinihingal as

Impaired Gas Exchange related to

CommunityAcquired Pneumonia is defined as a lower

Short Term :

After 8hours

> Perform a complete respiratory assessment ;

> Because airway inflammation and mucous accumulation, pneumonia can cause

Short Term : The patient shall be relieved from dyspnea by

verbalized by the mother

Objective cue :

>difficulty of breathing

>nasal flaring

inflamed lung tissue and consolidatio n of mucous / ffluid in specific lung lobes preventing transfer of gases across the alveolar capillary cellular membrane

>shortness of breath/ exertional discomfort

>with presence of crackles on both lung lobes upon auscultation

> with non

respiratory tract infection of the lungs parenchyma with onset in the community or during thre first 2days of hospitalization. Pneumonia occurs when the offending organism stimulate inflammatory response the defense mechanism of the lung lo9se effectiveness and allow organisms to penetrate the sterile, lower respiratory tract, where inflammation develops. Inflammation occurs due to colonization of offending organization wherein there is the release of chemical

of Nursing Interventions, the patient will be relieved from dyspnea by participating in breathing exercises, effective coughing and use of oxygen as evidenced by absent of nasal flaring, shortness of breath, easy fatigability, etc.

respiratory rate, fluid in the lungs and participating in rhythm, chest increase the work of breathing expansion, ease of breathing, resulting in exercise, effective breathing, use of impaired gas exchange. coughing and use accessory muscles, These assessment of oxygen as pursed lip provide data use for evidenced by breathing, breath planning absence of nasal sounds, mucous flaring, shortness Interventions and expectoration, of breath, easy assessing progress. perioral cyanosis, fatigability. Etc. Sputum cultures identify tachypnea, dyspnea, pulse oximetry and the causative organisms, arterial blood gases monitor laboratory demonstrate decreased and diagnostic oxygen concentration, procedures such as chest x-ray will confirm sputum cultures, the presence of fluid in complete blood the lungs or areas of count, arterial blood Long Term : consolidation gases, etc. The patient shall have an improved ventilation and adequate oxygenation of lung tissue as evidenced by normal arterial blood gases, clear

Long Term :

After 1 to 3 days of Nursing

> Obtain subjective data from the patient or significant other, including history of chronic respiratory disease and history

> knowledge of the patient respiratory status contributes to information that can assist in determination

productive cough

> easy fatigability

>Tachycardia

> abnormal rate rhythm, depth of breathing

>Restlessness

>Confusion

>fever

O 2

mediators, attraction of neutrophils, accumulation of fibrinous exudates, red blood cells and macrophages. These would in turn trigger erythema swelling, edema and stimulation of nerve fibers, leading to pain. Goblet cells will increase mucus production in attempt to dilute amd wash away offending organisms out of the respiratory tract. Inflamed fluid-filler alveolar sacs cannot exchange O2 and CO2 effectively leading to hypoxia of the lung tissue and a significant ventilation-

Interventions, the patient will have an improved ventilation and adequate oxygenation of lung tissue as evidenced by normal arterial blood gases, patient will have a clear breath sounds, absence of purulent discharge

of smoking

> Assist patient to semi fowlers position

other factors that may have contributed to pneumonia or influence its treatment

Breathing sounds, absence of purulent discharges, etc.

> Sitting upright allows the diaphragm to descend, resulting in easier breathing >Take temperature every 4 hours > Infectious processes can cause an increase body temperature > Provide comfort measures change linen or clothing

>Following temperature spikes, linen and clothing may become saturated with perspiration

> Encourage adequate fluid intake to 2000

> Helps thin and liquefy secretions

perfusion mismatch s a t u r a t i o n o f l e s s t h a n 9 0 %

cc/day

> Assess mucous amount, color consistency.

>Helps to detect improving status of pneumonia, amount should be decreasing and viscosity should be thinning following interventions; green, brown or purulent mucus indicate continued presence of pneumonia

>Coughing and deep breathing cause alveoli to open and loosen mucous to help clear the airways >Encourage coughing and deep breathing with mucous expectoration

>Loosen mucous plugs thus increasing are available for gas

exchange > Provide chest physiotherapy postural drainage, chest percussion and vibration > To maintain airway patency > Elevate head of bed >Promotes optimal chest expansion and drainage of secretion

> Encourage frequent position changes

> Helps limit oxygen needs/ consumption > Encourage adequate rest and limit activities to with in patient tolerance. Promote calm and restful environment

> Administer

oxygen as ordered >Pneumonia increased mucous production and fluid retention in lungs which decreases adequate gas exchange; supplemental oxygen provides additional oxygen for tissue oxygenation

>Helps to stop the proliferation of microorganisms >Administer antibiotic as ordered and monitor for side effects. A d o

Problem No. 3 Ineffective Breathing Pattern Assessment Nursing Diagnosis Scientific Explanation Planning Nursing Intervention Rationale Evaluation

Subjective Cue: Nahihirapang huminga ang baby ko., as verbalized by the mother

O=Patient Manifested the following :

Ineffective breathing pattern related to thick tenacious secretions in the bronchi due to inflammatio n of lung tissue

>difficulty of breathing

>shortness of breath on exertion, paleness

CommunityAcquired is a disease process involving inflammation of lung tissue. It typically results when microorganisams enter the normally sterile lungs from the nasopharynx and produces inflammation of the lung parenchyma. Because of the inflammation of the alveoli are filed with fluid and mucus and oxygen and carbon dioxide exchange cannot take place at a alveolar capillary cellular membrane level due to blood flow decreases

Short Term :

After 4 hours of Nursing Interventions, the patient shall have a normal respiratory rate, rhythm, depth and reports a shortness of breath as evidence by decrease RR from 38 cpm to 16-20 cpm

> Assess respiratory system by noting respiratory rate, depth chest expansion, breath sounds, arterial blood gases, etc.

> Any of this abnormalities would indicate the studies of the respiratory system and progression of disease; also establishes a baseline comparison

Short Term :

> Assist Patient in assuming a highfowlers position or position of choice such as leaning forward or over bed table

>maximizes thoracic cavity space, decreases pressure from diaphragm and abdominal organs and facilitates use of accessory muscles

The patient shall have a normal respiratory rate, rhythm, depth of breathing and relief from shortness of breath as evidence by decrease RR from 38 cpm to 16-20 cpm

Long Term :

> Increase oral fluids to 2000-3000 ml/day as tolerated

>help to improve hydration status and decrease secretions.

After 2 days

> Provide chest

> mobilizes thick

> nonproductive cough

> with presence of rales on both lung lobe upon chest auscultation easily fatigability

(deceased perfusion of blood in the lungs)and leukocytes and fibrin consolidate in the affected part of the lung due to a decreased blood flow there is a decreased supply of oxygen to other tissues leading to ineffective breathing pattern

of Nursing Interventions, the patient shall be free from any signs and symptoms of hypoxia as evidenced by normal ABG, etc.

physiotherapy, bronchial tapping, vibration, etc.

secretions, and facilitates clearing of lung fields. Long Term :

>Assist with activities of daily living as required

>patient with pneumonia may lack sufficient oxygen reserves to perform activites; even eating may cause severe dyspnea

The patient shall be free from any signs and symptoms of hypoxia as evidenced by normal ABG, etc.

>severe dyspnea

> Teach patient how to decrease shorthness of breath by restructuring activities

> Knowing how to control shortness of breath will help cope and have optimal functioning

>Teach pulmonary hygiene; prevention of spread of infection

> Preventing spread of infection and subsequent

hospitalization >Provide humidified low flow of oxygen as ordered >Provide some supplemental oxygen to improve oxygenation and to make secretions less viscous

>Administer bronchodilators and expectorants

>Enhances expectoration of secretions of previously ineffective cough

> Administer antibiotics as ordered

>Helps to prevent or eradicate infections to reduce secretions and to end to inflammation