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As verbalized by the patients mother. Objective: BP: 60/40 PR: 167 bpm Temp: 37.2C RR: 71 cpm Tachypneac Dyspneac Tachycardiac With DOB and crackel sounds on left lung Change in respiratory rate and rhythm With series of productive cough
NURSING DIAGNOSIS Ineffective airway clearance related to excessive mucus secondary to pneunonia
INFERENCE Pneumonia is inflammation of the terminal airways and alveoli caused by acute infection by various agents. Pneumonia can be divided into three groups: community acquired, hospital or nursing home acquired (nosocomial), and pneumonia in an immunocompromis ed person.Causes include bacteria (Streptococcus, Staphylococcus, Haemophilus influenzae, Klebsiella, Legionella). Community Acquired Pneumonia (CAD) is a disease in which individuals who have not recently been hospitalized develop an infection of the lungs. It is an acute inflammatory condition thats result from aspiration of
PLANNING After 8 hours of nursing inter vention the patient would be able to: Maintain airway patency Demonstrate reduction of congestion with breath sounds clear, respirations noiseless, improve oxygen exchange. Display absence of tachypnea, dyspnea and tachycardia
NURSING INTERVENTION Independent: Elevate head of the bed/ change position every 2 hours and prn.
RATIONALE To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of/ventilation of different lung segment
EVALUATION After 8 hours of nursing inter vention the patient: Maintained airway patency Demonstrated reduction of congestion with breath sounds clear, respirations noiseless, improve oxygen exchange. Displayed absence of tachypnea, dyspnea and tachycardia The goal is met
Monitor v/s signs especially respiratory rate, note for respiratory distress Monitor respirations and breath sounds, noting rate and sounds Evaluates clients cough or gag reflex and swallowing ability Suction naso/tracheal/oral prn
Indicatives of respiratory distress and/or accumulation of secretions To determine ability to protect own airway
To clear airway when excessive or viscous secretions are blocking airway or client is unable to swallow
or cough effectively Standby Oxygen at bedside Insert oral airway as needed For emergency
To maintain anatomic position of tongue and natural airway, especially when tongue/ laryngeal edema or thick secretions may block airway Helps on secretion of excessive mucus Hydration can help liquefy viscous secretions and improve secretion clearance