CUES NURSING ANALYSIS GOALS and NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTION

Subjective: Impaired gas Community- Goal: After 8 hours of
“Inuubo ako at exchange acquired pneum After 8 hours of nursing
nahihirapan related to onia (CAP) is
nursing intervention, the
akong inflammatory a disease in intervention, the
client was able to
makahinga.” process in the which individuals client will be able to
establish a normal
lung who have not establish a normal
“Mas parenchyma recently been and effective and effective
nakakahinga and alveoli as hospitalized respiratory pattern. respiratory
ako ng maayos manifested by develop pattern.
kapag ganitong restlessness. an infection of
may Oxygen. the lungs (pneum Objectives:
Kapag wala, ang onia).
hirap talaga Independent Independent
huminga at saka CAP is a common 1. After 30 minutes 1.Monitor Tachypnea, stridor,
matanda na rin illness and can of intervention, the respiration and crackles or
ako.” affect people of client would be able breath sounds wheezes are
all ages. CAP to have normal indicative to
Objective: often causes breath respiration repiratory distress
Restlessness problems like and breath sounds and/or
difficulty in within 20 minutes. accumulation of
Nasal flaring breathing, fluid
fever, chest (Nurse's Pocket
Crackles heard pains, and a Guide by Doenges
upon cough. CAP et al pp.78)
auscultation on occurs because
both lung filed the areas of the
lung which 2. After 30 minutes 2. Place the client in Positioning the
Oxygen via absorb oxygen of nursing high fowler’s client in high
nasal cannula (alveoli) from the intervention, the position. fowler's position
atmosphere client would be able promote lung
become filled to have easier expansion.
with fluid and breathing. (Fundamentals of
cannot work Nursing by Kozier
effectively pp.789)

Pneumonia
also is the 3. After 45 minutes 3.1 Increased fluid Hydration can help
inflammation of of nursing intake. liquefy viscous
the lung intervention, the secretions and
parenchyma client would be able improve secretion
caused by to mobilize clearance.
various secretions. (Nurse's Pocket
microorganisms, Guide Doenges.79)
including
bacteria,
mycobacteria, 3.2Encourage Promotes optimal
chlamydiae, frequent position chest expansion
mycoplasma, changes and deep and drainage of
fungi, parasites breathing/coughing secretions.
and viruses. As exercises.
the lung
parenchyma and
alveoli of the 3.3 Suctioning Suction is used to
lungs are clear airway when
inflamed it excessive or
impairs gas viscous secretions
exchange due to are blocking the
the alterations in airway or client is
the alveoli which unable to cough
is the site for effectively.
actual gas (Nurse's Pocket
exchange. Guide by Doenges
et al pp.78)

3.4 Perform Chest Chest

 Physiotherapy. Physiotherapy is
used to
mechanically
dislodge tenacious
secretions from the
bronchial walls.
(Nursing Care
Management Skill
Manual pp.60)

Dependent: Dependent:
4. After 15 minutes 4.1 Administer Bronchodilators
of nursing bronchodilators as are anti-
intervention, the ordered by the inflammtory drugs,
client would be able physician. excpectorants and
to take the cough
medications and suppressants that
treatment may treat
prescribed by the respiratory
physician within the problems.
order time and date (Fundamentals of
of administration. Nursing by Kozier
pp.1369)

4.2 Perform oxygen Administration of

therapy or oxygen to client to
administer oxygen prevent or relieve
by nasal cannula. hypoxia.
(Nursing
CareManagement
Skill Manual pp.55)
Interdependent:
5. After 15 minutes 5.1 Instruct relatives Nebulization is
of nursing to perform proper performed to
intervention, the nebulization deliver finer mist at
client's relatives a faster rate to
would be able to moisten
perform proper membrane.
humidification and (Nursing
administer CareManagement
medication via Skill Manual pp.69)
nebulization.