CUES NURSING SCIENTIFIC GOAL AND NURSING RATIONALE

DIAGNOSIS BASIS OUTCOME ACTION AND OF NURSING

ORDERS ORDERS
Subjective Impaired gas Community Goal: Independent:
exchange acquired After 8 hours of 1. Monitor -Tachypnea,
“Gi ubo ko
related to pneumonia nursing respiration and stridor, crackles
maam unya mag inflammatory (CAP) is a intervention, thr breath sounds or wheezes are
process in the disease in which client will be indicative to
lisod ko
lung individuals who able to establish respiratory
ginhawa” as parenchyma and have not a normal and distress and/or
alveoli as recently been effective accumulation of
verbalized by
manifested by hospitalized respiratory fluid
the patient. restlessness. develop an pattern.
infection of the
lungs Objectives: 2. Place the -Positioning the
Objective: (pneumonia). patient in high client in high
Independent: fowler’s fowler’s
-Restlessness position.
CAP is a 1. After 30 position
-Nasal flaring common illness minutes of promote lung
and can affect intervention, the expansion.
-Crackles heard
people pf all client would be
upon ages. CAP often able to have a 3.1. Increased -hydration can
causes problems normal breath fluid intake help liquefy
auscultation on
like difficulty in respiration and viscous
both filed breathing, fever, breath sounds secretions and
chest pain, and a within 20 min. improve
cough. CAP secretion
occurs because 2. After 30 min. clearance
the areas of the of nursing
lung which intervention, the 3.2. Encourage -Promotes
absorb oxygen client would be frequent optimal chest
(alveoli) from able to have position changes expansion and
the atmosphere easier breathing and deep drainage of
become filled 3. After 45min. breathing/cough secretion
with fluid and of nursing ing exercises
cannot work intervention, the
effectively client would be
able to mobilize 3.3. Suctioning -Suction is used
Pneumonia also secretions. to clear airway
is the when excessive
inflammation of Dependent: or viscous
the lung secretions are
parenchyma 1. After 15min. blocking the
caused by of nursing airway or client
various intervention, the is unable to
microorganisms, client would be cough
including able to take the effectively.
bacteria, medications and
mycobacteria, treatment 3.4. Perform
chlamydia, prescribe by the chest -Chest
mycoplasma, physician within physiotherapy physiotherapy is
fungi, parasites the order time used to
and viruses. As and date of mechanically
the lung administration. dislodge
parenchyma and tenacious
alveoli of the Interdependent: secretions from
lungs are 1. After 15min. the bronchial
inflamed it of nursing walls.
impairs gas intervention, the Dependent:
exchange due to client’s relatives 4.1. Administer
the alterations in would be able to bronchodilators -
the alveoli perform proper as ordered by Bronchodilators
which is the site humidification the physician are anti-
for actual gas and administer inflammatory
exchange. medication via drugs,
nebulizer expectorants
and cough
suppressants
that may treat
respiratory
problems.

4.2. Perform
oxygen therapy -Administration
or administer of oxygen to
oxygen by nasal client to prevent
cannula. or relieve
hypoxia.
5.1. instruct
relatives to -Nebulization is
perform proper performed to
nebulization. deliver finer
mist at a faster
rate to moisten
membrane.