List of Prioritize Nursing Problems

Problem Justification

Ineffective Airway Clearance due to the Chosen as our first priority nursing
Inability to Clear Secretions from the problem because our patient experiences
Respiratory Tract difficulty of breathing caused by
inflammation and increased secretions

Our second priority nursing problem

Ineffective Breathing Pattern as Evidenced because constriction of affected alveoli our
by Inadequate Ventilation patient is tachypneic .The body is unable to
meet the metabolic demands of O2 & CO2
exchange.

Insufficient oral intake ,fever and

Deficient Fluid volume depressed respirations could result to fluid
loss in the body

Related to infection and mild dehydration

Hyperthermia : Body temperature elevated the patient was experiencing fever
above normal range

To prevent spread of infection because of

Risk for Infection inadequate primary defenses
 Nursing Care Plan

Ineffective Airway Clearance due to Inability to Clear Secretions from the Respiratory Tract

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective -Ineffective Short term Independent : -Altered breathing -After 8 hours of

data: Airway goal: -Assess the rate, pattern may occur nursing
-Change in Clearance -After 30 rhythm, and together with use intervention, clear
rate, depth of due to the mins -1hr of depth of of accessory breath sounds was
respiration Inability to nursing respiration, chest muscles to already heard,no
Clear intervention, movement, and increase chest more dyspnea
- Use of Secretions the patient use of accessory excursion to noted and was
accessory from the will maintain muscles. facilitate effective starting to clear
muscles – Respiratory patent - Assess cough breathing. secretions as
Tract airway ; effectiveness -Explain with encouraged by his
Decreased absence of and productivity demonstration to significant other.
breath sounds dyspnea significant other
over affected that coughing is
lung areas Long term the most effective
Goal: way to remove
RR:50 breaths/ After the end secretions
min of the shift - Auscultate - Decreased
PR:145bpm the patient lung fields, airflow occurs in
with its noting areas of areas with
significant decreased or consolidated
other will absent airflow fluid. Bronchial
demonstrate and adventitious breath sounds can
behavior to breath sounds: also occur in these
achieve crackles, consolidated areas
airway wheezes.
clearance - Elevate head of
bed, change - Doing so would
position lower the
frequently. diaphragm and
promote chest
expansion,
aeration of lung
segments,
mobilization and
expectoration of
secretions.
-Advise - Fluids can thin
significant other the mucus and
to increase help the sinuses to
intake of water drain.
as tolerated
Dependent:
- Administer - To improve
 medications as respiration and
indicated reduce discomfort
- To facilitate
-Administer breathing by
humidified decreasing the
oxygen per viscosity of
doctor’s order secretions.
 Ineffective Breathing Pattern as Evidenced by Inadequate Ventilation

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective Data: -Ineffective Within 1-2 Independent -The average rate

Breathing hours of -Assess and record of respiration for a
-With retractions or Pattern as nursing respiratory rate 2 year old is 30 to
flaring of nostrils Evidenced by intervention, and depth at least 40 breaths per
Inadequate patient every hour. minute. It is
-Presence of rhonchi Ventilation maintains important to take
upon auscultation relaxed action when there
breathing at is an alteration in
-Purulent sputum normal rate the pattern of
and depth and breathing to detect
-Dyspneic absence of early signs of
dyspnea. respiratory
- Alteration of compromise.
patient’s O2/CO2 - Unusual
ratio breathing patterns
may imply an
-RR-50 breaths/min underlying disease
SpO2 -89% process or
- Observe for dysfunction
breathing patterns. - Paradoxical
movement of the
abdomen (an
inward versus
outward movement
during inspiration)
is indicative of
- Monitor for respiratory muscle
diaphragmatic fatigue and
muscle fatigue or weakness.
weakness - A sitting position
(paradoxical permits maximum
motion). lung excursion and
chest expansion.
- Prevents
crowding of the
diaphragm.
- These allow
sufficient
mobilization of
secretions.
- Place patient with
proper body
alignment for
maximum
breathing pattern.
- Encourage small
frequent meals.
Educate significant
other to assist
patient about
proper breathing,
coughing, and
splinting methods.
Assessment Diagnosis Planning Intervention Rationale Evaluation

-Offer patient something -This conserves -Before the end of

to keep him entertained energy and avoids the shift patient
while on bedrest to pace fatigue which can already display clear
activity as necessary. worsen shortness breath sounds with
of breath absence of dyspnea.
Dependent: SpO2-95%
-  To facilitate RR-40 breaths/min
-Administer medications adequate clearance -Appears more
with doctor’s order of secretions. relaxed and with
- To help patient decrease cough effort
Anticipate breathe better and noticed
supplemental oxygen improve
administration as blood oxygen leve
ordered ls.
 Deficient Fluid Volume

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective Data: Deficient -After 4-8 hours Independent Goal met:

Fluid of nursing -Assess vital sign -Elevated -Patient
-Barely drinks water volume intervention the changes: temperature and demonstrates fluid
patient will show increasing prolonged fever balance evidenced
-With fewer than six signs of temperature, increases metabolic by individually
wet diapers in 24 improved fluid prolonged fever rate and fluid loss appropriate
hours  balance, e.g., tachycardia. through evaporation. parameters, e.g.,
moist mucous -Tachycardia may moist mucous
- Shows little interest membranes, indicate systemic membranes, good
in taking milk for good skin turgor, fluid deficit skin turgor, prompt
feeding stable vital signs. -Assess skin capillary refill,
turgor, moisture stable vital signs
-Irritable of mucous -They are indirect
membranes indicators of
-Temp-38.5 adequacy of fluid
-PR-150bpm -Monitor intake volume
-RR-50 and output
breaths/min (I&O), noting - Provides
color, character information about
of urine. adequacy of fluid
Calculate fluid volume and
balance. replacement needs.

-Do sponge bath

Dependent:
-Give antipyretic -To reduce body
medications as temperature
prescribed.

- Antipyretic
medications lower
body temperature by
blocking the
synthesis of
prostaglandins that
-Provide act in
supplemental IV the hypothalamus
fluids as
necessary. - In presence of
reduced intake and/or
excessive loss, use of
parenteral route may
correct deficiency.