Problem #1: Ineffective Airway Clearance ASSESSMENT S: NURSING DIAGNOSIS SCIENTIFIC EXPLANATION Normally the lungs are free

e from secretions. But with Bronchopneumoni a, bacteria are invading the lung parenchyma thus, producing inflammatory process. And this response leads to filling of the alveolar sacs with exudates leading To consolidation. Due to consolidation the airway is narrowed thus wheezes is being heard, DOB in some cases orthopnea is observed. PLANNING Short Term: After 4 hours of nursing Intervention s the patient will demonstrate behaviors of improve or maintain clear airway. Long Term: After 5 days of nursing intervention s the patient will demonstrate absence or reduction of congestion with breath sounds clear, respirations noiseless, INTERVENTION INDEPENDENT: Establish rapport with patient. Provide A.M. Care Monitor respirations and breathe sounds, noting rate and sounds. Evaluate clients cough/gag reflex and swallowing ability. Provide well ventilated environment. Increase fluid intake RATIONALE For good nursepatient relationship and for cooperation. For good hygiene. To determine accumulation of secretions and respiratory distress. To determine ability to protect airway. EVALUATION Short Term: After 4 hours of nursing Interventions the patient shall demonstrate behaviors of improve or maintain clear airway. Long Term: After 5 days of nursing interventions the patient shall demonstrate absence or reduction of congestion with breath sounds clear, respirations noiseless, and improved oxygen exchange.

Ineffectiv e O: airway Manifested: clearance Presence related to of cracles on retained both lung fields secretions as upon evidenced auscultation by presence Changes in of wheezes respiratory rate on both lung restlessnes fields and changes in s respiratory rate. May Manifest: Difficulty in vocalizing Orthopnea Excessive sputum Cough ineffective or absent

To improve comfort and breathing pattern Hydration can help liquefy viscous secretions and improve secretion

and improved oxygen exchange.

clearance. Position patient appropriately, side-lying or head of bed elevated. Auscultate breath sounds and assess air movement. Observe for signs of respiratory distress. INTERDEPENDEN T: Give expectorants or bronchodilator s as ordered. To provide comfort and to prevent vomiting with aspiration into lungs. To ascertain status and note progress.

For timely intervention.

To improve airway patency.

Problem #2: Impaired Gas Exchange

ASSESSMENT

NURSING DIAGNOSI S Impai red gas exchange related to thick secretion s

SCIENTIFIC EXPLANATION Pneumonia arises from normal flora present in patients whose resistance has been altered or from aspiration of flora present in the oropharynx. It affects both ventilation and diffusion. An inflammatory reaction can occur in the alveoli, producing an exudate that interferes with the diffusion of oxygen and carbon dioxide. White blood cells, mostly neutrophils, also migrate into the alveoli and fill

PLANNING

INTERVENTION

RATIONALE

EXPECTED OUTCOME Short Term: The patient shall have demonstrated improve ventilation and oxygenation of tissues within the absence of respiratory distress.

S: O: Manifested: Restlessness Irritability Abnormal breathing Nasal Flaring May Manifest: Diaphoresis Tachycardia Dyspnea Abnormal Skin Color

Short term: After 4 to 6 hours of nursing intervention s, the patient will be able to demonstrate improve ventilation and oxygenation of tissues within the absence of respiratory distress. Long Term: After 2 to 3 days of nursing intervention s, the patient will be able to participate in actions to

Establish rapport with patient. Provide A.M. Care. Assess patients general condition Monitor and record Vital Signs Evaluate lung volumes and forced vital capacity Auscultate for breath sounds

For good nursepatient relationship and for cooperation. For good hygiene. To know and determine patients needs To obtain baseline data for future comparison To assess for respiratory insufficiency

To identify areas of consolidation and determine possible bronchospasm or obstruction.

Long term: The patient shall have participated in actions to maximize oxygenation.

the normally aircontaining spaces. Areas of the lungs are not adequately ventilated because of secretions and mucosal edema that cause partial occlusion of the bronchi or alveoli, with a resultant decrease of alveolar oxygen tension, thus there is an impaired gas exchange.

maximize oxygenation.

Encourage frequent position changes Encourage periods of rest/ adequate rest Position patient appropriately Elevate head of the patient Provide psychological support on the significant others Emphasize the importance of nutrition Keep environment allergen free

To promote lung expansion and drainage of secretions To help limit oxygen consumption To maintain airway patency To allow mobilization of secretions To have a baseline data for future comparison

To reduce anxiety

To improve stamina and reduce the work of breathing

 Review laboratory results Dependent: Administration of bronchodilator s as indicated Administration of medications as indicated

To reduce irritant effect of dust on airways

To humidify secretions

To treat underlying conditions

Problem #3: Activity Intolerance ASSESSMENT NURSING DIAGNOSI S Activi ty intoleranc e related to Imbalanc e between SCIENTIFIC EXPLANATION Decrease oxygen carrying capacity of Hgb and decreased nutrition in cells results to decreased ATP production since PLANNING INTERVENTION RATIONALE EXPECTED OUTCOME Short Term: The patient shall have identified techniques to enhance activity tolerance.

S: O: Manifested: Tachypnea Weakness Fatigue

Short Term: After 2 to 4 hours of nursing intervention s the patient will be able to use

Establish rapport with patient. Provide A.M. Care. Assess

For good nursepatient relationship and for cooperation. For good hygiene. To know and determine patients

May Manifest: Tachycardia Exertional dyspnea Abnormal heart heart rate

oxygen supply and demand as evidence by tachypne a, weakness and fatigue.

oxygen is needed for oxidation of CHO/glucose it will result to decreased energy or muscle weakness and then activity intolerance occur.

identified techniques to enhance activity tolerance. Long term: After 2 to 4 days of nursing intervention s the patient will be able to report measurable increase in activity tolerance.

patients general condition Monitor and record Vital Signs Note presence of factors contributing to fatigue Note clients reports of weakness, fatigue, pain, difficulty accomplishing tasks, and/or insomnia. Ascertain ability to stand or move about degree of assistance necessary/use of equipment. Adjust

needs To obtain baseline data for future comparison Fatigue affects both the clients actual and perceived ability to participate in activities. Symptoms may be result of/or contribute to intolerance activity.

Long term: The patient shall have reported measurable increase in activity tolerance.

To determine current status and needs associated with participation in needed/desired activities. To prevent overexertion

activities To reduce fatigue Plan care to carefully balance rest periods with activities Provide positive atmosphere, while acknowledging difficulty of the situation for the client. Promote comfort measures and provide for relief of pain Plan for progressive increase of activity level/participat ion in exercise training, as tolerated by client.

To help minimize frustration and rechannel energy

To enhance ability to participate in activities.

Both activity tolerance and health status may improve with progressive training.

To enhance sense of well being

 Encourage client to maintain positive attitude; suggest use of relaxation techniques, such as visualization/g uided energy, as appropriate

Problem #4: Impaired Social Interaction ASSESSMENT S: O: Manifested: Discomfort in social situations Use of nonverbal cues (turning away) Frustration NURSING DIAGNOSIS Impaired social interacti on related to communi cation barrier as evidence d by SCIENTIFIC EXPLANATION Impaired social interaction is listed as a type of or relatedsymptom for symptom Social problems. Difficulty relating to other people; Insufficient or excessive quantity or PLANNING Short Term: After 23hours of nursing intervention s the patient will verbalize awareness of factors causing or promoting INTERVENTION Establish rapport with patient. Provide A.M. Care. Explore the patients feelings regarding fears in a social RATIONALE For good nursepatient relationship and for cooperation. For good hygiene. Assists the patient to examine social experience and verbalize feelings. Encourages the therapeutic EXPECTED OUTCOME Short Term: The patient shall have verbalized awareness of factors causing or promoting impaired social interaction.

 Willful refusal to speak May Manifest: Dysfunctional Interaction with others Difficulty in comprehendin g

ineffective quality of social exchange. Impaired social interaction can be seen with Verbalized or observed inability to receive or communicate a satisfying sense of belonging, caring, interest, or shared history, observed discomfort in social situations, dysfunctional interaction with peers, family, and/or others, family report of change of style or pattern of interaction.

impaired social interaction. Long term: After 4-6 days of nursing intervention s the patient will develop effective social support system.

situation. Assist the client to put the fears in perspective and work through the fears. Evaluate the patients communication skills, identify areas for developmen t. Review social history with client/SOs going back far enough in time. Ascertain ethnic/cultural or religious implications for the client. Review medical history noting stressors of physical/long term illness,

relation-ship.

Improves communication skills

Long term: The patient shall have developed effective social support system.

To note when changes in social behavior or patterns of relating occurred.

These impact choice of behaviors/may even script interactions with others. To determine the cause of changes in behavior.

mental illness, emotional disorders. Observe client while relating to family Determine clients use of coping skills and defense mechanisms. Provide positive reinforcement for client's voluntary interactions with others. Spend time with client. This may mean just sitting in silence for a while. Encourage client to verbalize problems, and feeling of

To note prevalent interaction patterns. Affects ability to be involved in social situations. Positive reinforcement enhances selfesteem and encourages repetition of desirable behaviors. Presence may help improve client's perception of self as a worthwhile person. To enhance comfort for better communication

discomforts.

Problem #5: Fatigue ASSESSMENT S: O: Manifested: Lack of energy Lethargic May Manifest: Compromised Concentration Introspection Decreased Performance NURSING DIAGNOSIS Fatigue related to poor physical condition as evidence by lack of energy and lethargic. SCIENTIFIC EXPLANATION An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level. Fatigue is a subjective complaint with both acute and chronic illnesses. In an acute illness fatigue may have a protective function that keeps the person from sustaining injury from overwork in a weakened condition. As a PLANNING Short Term: After 2 days of nursing interventions the patient will demonstrate improved sense of energy. INTERVENTION Establish rapport with patient. Provide A.M. Care. Identify presence of physical and psychological conditions. RATIONALE For good nursepatient relationship and for cooperation. For good hygiene. It may be affecting current situation. EXPECTED OUTCOME Short Term: The patient shall have demonstrated improved sense of energy. Long term: The patient shall have participated in recommende d treatment program.

Long term: After 3 days of nursing Assess vital interventions signs the patient will be able to participate Determine in presence/degr recommende ee of sleep d treatment disturbance. program. Note daily

To evaluate fluid status and cardiopulmonary response to activity. Fatigue can be a consequence of sleep deprivation. Helpful in determining pattern and timing

common symptom, fatigue is associated with a variety of physical and psychological conditions. Fatigue is a prominent finding in many viral infections such as hepatitis.

energy patterns. Plan interventions to allow individually adequate rest periods. Schedule activities for periods when client has the most energy. Avoid or limit exposure to temperature and humidity extremes. Encourage nutritious foods.

of activity. To maximize participation.

Can negatively impact energy level.

To promote energy.