NURSING RATIONALE TO THE NURSING RATIONALE TO THE EVALUATION

PROBLEM PROBLEM INTERVENTIONS INTERVENTIONS

Difficulty Of > Ineffective Independent > After 30 mins. Of

Breathing breathing pattern nursing
related to > Monitor respiratory >With secretions in the intervention the
patterns, including airway, the respiratory
Subjective Cues: community client manifested
rate, depth and effort. rate will increase
acquired lessened difficulty
“Nahihirapan sya pneumonia as of breathing as
> Positioning of the > To provide patent,
sa paghinga as manifested by patient with head on unobstructed airway, manifested by
verbalized by the nasal flaring, pale mid line, with slight maximum lung decreased in RR
patients daughter” skin, abnormal flexion. excursion from 24 cpm to 19
breath sounds, cpm with the
Objective Cues: rapid shallow > Auscultating patient’s > To monitor for the absence of nasal
breathing and RR of chest presence of abnormal flaring and the
> Nasal flaring 24 cpm. breath sounds presence of calm
> Abnormal breath breathing.
> Provide chest and > Chest physiotheraphy
sounds
back clapping with facilitates the
> Rapid shallow vibration
Goal Met.
loosening of secretions
breathing
> Promotes chest
> V/S taken as > Encourage deep expansion
follows: breathing
>Helps in giving
Temp: 37.5 Dependent adequate oxygen to the
PR: 57 client
RR: 24 > Gave supplemental
oxygen as ordered
BP: 140/80
(2LPM via nasal
mmhg
cannula)
> Fluids are required to
Collaborative replace losses and aid
in mobilization of
> Provide supplemental secretions
fluids
> Assess the condition
of the client

> Obtained blood

specimen for Arterial
Blood Gas Study