Nursing Care Plan

GROUP 4

Patients Name: T.S.

Room:
Age: 68 years old
Date of Admission: February 14, 2015
CC: Community Acquired Pneumonia High risk
Attending Physician: Dr. M.S.

General Objective:
To facilitate the maintenance of oxygen
supply to all body cells

Subjective Cues
*As verbalized by the folks:
Di sya mayo ka ginhawa kag ga sakit iya nga ulo.
Di sya mayo katulog kung gab.i kay nabudlayan sya
maginhawa.
Gindala sya namon sa ospital kay nabudlayan gid sya
maginhawa.

Objective Cues

Temp: 36.8 C
HR: 85 bpm
RR: 26 cpm
BP: 110/70 mmHg
Abnormal breath sound: wheezing
Restlessness and Irritability noted
Coughing without sputum production
Dyspnea noted
Capillary refill: 3 seconds

Others
Chest x-ray revealed progression of bilateral lung pneumonia.
Pulmonary congestion noted. NGT and ET tubes still in place.
No signs of pleural effusion.
Gram staining in sputum via endotracheal aspirate result:
Gram stained smear shows many pus cells and few epithelial
cells.
Culture and sensitivity result: No growth after 5 days of
intubation.
ABG: metabolic acidosis uncompensated

NURSING
DIAGNOSIS

Ineffective airway
clearance r/t
increased
tracheobronchial
secretions 2
Community
Acquired
Pneumonia High
Risk

RATIONALE

S pneumoniaeis an example of a typical

extracellular bacterial pathogen.
Pathogenicity requires adherence to host
cells, along with the ability to replicate
and to escape clearance and/or
phagocytosis. The organism must then
gain access to areas where it can
manifest infection, either via direct
extension or lymphatic or hematogenous
spread.

SPECIFIC
OBJECTIVE

Within 3
days of
rendering
nursing care,
the client will
be able to
maintain a
patent
airway.

INTERVENTION

RATIONALE

INDEPENDENT
Assess airway for patency

To check for any obstruction

Assess the level of consciousness and skin

tone.

To evaluate the changes in gas exchange

which affects the level of consciousness and
skin tone.

Auscultate lungs for presence of normal or

adventitious breath sounds:
-Decreased or absent breath sounds
-Wheezing
-Coarse sounds

May indicate presence of mucous plug or

other major airway obstruction.
May indicate increasing airway resistance.
May indicate presence of fluid along larger
airways.

Assess respirations; note quality, rate,

pattern, depth, flaring of nostrils, dyspnea

Abnormality indicates respiratory

compromise.

INTERVENTION

RATIONALE

INDEPENDENT
Assess changes in mental status.

Assess cough for effectiveness and

productivity.

Note presence of sputum; assess

quality, color, amount, odor, and
consistency.

Assess patient's knowledge of

disease process.

Increasing lethargy, confusion,

restlessness, irritability can be early
signs of cerebral hypoxia.
Consider possible causes for
ineffective cough: respiratory muscle
fatigue, severe bronchospasm, thick
tenacious secretions, and others.
May be a result of infection,
bronchitis, chronic smoking, and
others. A sign of infection is
discolored sputum (no longer clear or
white); an odor may be present.
Patient education will vary
depending on the acute or chronic
disease state as well as the patient's
cognitive level.

INTERVENTION

RATIONALE

INDEPENDENT
Assist patient in performing
coughing and breathing maneuvers:

To improve productivity of the cough

-Optimal positioning (sitting position)

-Use of pillow or hand splints when
coughing
-Use of abdominal muscles for more
forceful cough
-Importance of ambulation and
frequent position changes.

These methods help maintain

adequate lung expansion thus
preventing buildup of secretions and
atelectasis.

Position the client in semi-fowlers

position by elevating the head of the
bed

To facilitate clearing of secretions.

It promote better lung expansion and
improved air exchange.

INTERVENTION

RATIONALE

INDEPENDENT
Encourage oral intake of fluids
within the limits

To prevent drying of secretions

Promote energy conservation

techniques.

To prevent fatigue

Demonstrate and teach coughing,

deep breathing, and splinting
techniques

So patient will understand the

rationale and appropriate techniques
to keep the airway clear of secretions.

Teach client and SO about

environmental factors that can
precipitate respiratory problems.

To limit impact on client's breathing.

INTERVENTION
COLLABORATIVE
Monitor arterial blood gases (ABGs).
If cough is ineffective, use
nasotracheal suctioning as needed
Institute appropriate isolation
precautions for positive cultures

RATIONALE

Increasing PaCO2 and decreasing

PaO2 are signs of respiratory failure.
To remove sputum and mucous
plugs.
To avoid the spread of
microorganisms.

Monitor pulse oximeter as indicated

Administer oxygen at lowest
concentration indicated and
prescribed respiratory medications.
If secretions cannot be cleared,
anticipate the need for an artificial
airway (intubation).

To verify maintenance or
improvement in O2 saturation.
For management of underlying
pulmonary condition, respiratory
distress, cyanosis.
To help facilitate removal of
tenacious sputum.

INTERVENTION

RATIONALE

COLLABORATIVE
Administer diuretic (furosemide)
IV/stock 40mg/2mL/0.3cc every 12
hours, as ordered.

To increase water excretion.

Administer oxygen at lowest

concentration indicated and prescribed
repiratory medications.

For management of underlying

pulmonary condition, respiratory
distress.

Monitor pulse oximetry, as indicated.

To verify maintenance/
improvement in O2 saturation

EVALUATION
After 3 days of rendering effective
nursing care, the client with ineffective
airway clearance was able to restore a
patent airway as evidenced by stable
and normal vital signs (BP: 110/70
mmHg, RR: 20 cpm, PR: 80 bpm, Temp:
36.7 C), clear breath sounds as
manifested by absence of wheezes,
cough effectively through capability to
expectorate all accumulated secretions.