HOLY NAME UNIVERSITY
College of Health Sciences
Name of Patient: _Karl___________________________________ Age: ___42_____________________ Status: ______Married________________________________
Address: ____________________________________________________ Date: ____________________ Ward: __________________________ Bed No: ___________________
Impression: ______________________________________________________________________________________________________________________________________
ASSESSMENT/ DIAGNOSIS
PROBLEM CUES/NRSG. DX RATIONALE OF THE
PROBLEM
Subjective cues: Pneumonia can affect
Mr. Karl Verbalized people of all ages. The
shortness of breath infection causes the lungs'
air sacs to become
inflamed and fill up with
fluid or pus.
Swelling and mucus can
make it harder to move air
through the airways,
making it harder to
breathe. That can make it
hard for the oxygen you
breathe in to get into your
bloodstream, this leads to
shortness of breath,
difficulty breathing and
feeling more tired than
normal.
Department of Nursing
Tagbilaran City, Bohol
NURSING CARE PLAN
PLANNING INTERVENTION
DESIRED BEHAVIORAL NURSING RATIONALE EVALUATION
OUTCOME(S) OUTCOME(S) INTERVENTIONS
After 3 days of After 8 hours of Independent: Goal met:
continuous intervention, the The patient was
intervention the patient will be able - Assess cough - Coughing is the able to identify
patient will be able to: effectiveness and most effective way to methods to
to: -demonstrate productivity remove secretions. enhance secretion
-identify methods to behaviours to Pneumonia may removal and avoid
enhance secretion achieve air way cause thick and specific factors that
removal clearance tenacious secretions inhibit effective
-identify and avoid -maintain a patent in patients. airway clearance
specific factors that airway with breath then also
inhibit effective sounds clearing. - Suction as indicated: -Stimulates cough or demonstrate a
airway clearance. frequent coughing, mechanically clears patent airway
adventitious breath airway in a patient clearance.
sounds, desaturation who cannot do so
related to airway because of ineffective Goal not met:
secretions. cough or decreased
level of The patient wasn’t
consciousness. able to avoid
- Encourage - Helps mobilize specific factors that
ambulation. secretions and inhibits effective
 reduces atelectasis. airway clearance
and not able to
- Increasing the maintain patent
humidity will airway clearance.
- Use humidified decrease the viscosity
oxygen or humidifier of secretions. Clean
at the bedside. the humidifier before
use to avoid bacterial
growth
Dependent:
- Administer - Mucolytics increase
medications, as or liquefy respiratory
indicated secretions.,
expectorants
- increase productive
cough to clear the
airways by liquefying
lower respiratory
tract secretions and
reducing their
viscosity,
bronchodilators are
medications used to
facilitate respiration
by dilating the
airways, and
analgesics are given
to improve cough
effort by reducing
discomfort but
should be used
cautiously because
they can decrease
cough effort and
 depress respirations.

- Assist with - Bronchoscopy is

bronchoscopy and occasionally needed
thoracentesis, if to remove mucous
indicated. plugs, drain purulent
secretions, and
obtain lavage
samples for culture
and sensitivity and
thoracentesis is done
to drain associated
pleural effusions and
prevent atelectasis.

Objective Cues:
He is anxious because he
has HIV and pneumonia
and his wife is cheating on
him.
He complains shortness of
breath, fever and fatigue
Nursing Diagnosis:
Ineffective Airway
Clearance as related to
pneumonia as evidence by
shortness of breath.