Assessment Nursing Diagnosis

Inference Planning Nursing Interventions Rationale Evaluation

Subjective Cues:

Objective Cues: Presence of

Body Weakness

GCS= 11 NGT ET Tube RR= 15bpm Crackles Left

base of the lungs

Symmetrical Chest Expansion

PNSS 1L x KVO Right Arm 13-14gtts

Ongoing Blood Transfusion at Left arm

For RECHECKING of Hourly monitoring of O2 Saturation

ABG to be followed

Chest X-ray Result of

Ineffective airway clearance related to the accumulation of secretions as evidence by decrease in respiratory rate and NGT and ET tube attached and crackles at the left base of the lungs

Irritant during inhalation due to

microbialagents

Inflammatory Responses

Tissue Injury

Vascular Responses

Increase production of

secretions

Airway constriction

Dyspnea

After 8 hours of nursing interventions the patient secretions shall be mobilized and airway shall be maintained to be free of secretions as evidence by decrease secretions and clear lung sounds during auscultation

Independent:1. Assess patient in semi

fowlers position

2. Turn Patient side to side Q2

3. Perform Chest Physiotherapy(CPT)

4. Assess rate of respirations and chest movement

5. Auscultate lung fields To note the areas of decrease airflow and adventitious sounds (Crackles)

Dependent: 1. Administer Salbutamol

1. Promoting chest expansion

2. It helps to liquefy the secretions by mobilizing

3. Is used to mobilize or loose secretions in the lungs

4. symmetrical chest movement are frequently present because of discomfort of moving chest wall or fluid in the lungs

5. Decrease airflow occurs in areas consolidated of fluid. Crackles can also occur in consolidated areas that can be heard during inspiration/expiration in response in fluid accumulation or thick secretions

1. To treat or prevent

After 8 hours of nursing interventions the patient secretions shall be mobilized and airway shall be maintained to be free of secretions as evidence by decrease secretions and clear lung sounds during auscultation

Pneumonial Right Lung

Smear shows presence of Gram + Cocci in 3 singly and in pairs with abundant leukocytes and fibrins

+ Ipratropium nebulizer Q6 PRN for DOB

2. Administer Meropenem 1gm TIV Q12 and c 500g TIV + Azithromycin 100cc PNSS Q6 via soluset

bronchospasms and facilitate expectoration of mucus and airway clearance.

Mechanism of Action:Salbutamol Inhibits the release of bronchoconstricting agents from mast cells, inhibits microvascular leakage, and enhances mucociliary clearance. Ipratropium It blocks muscarinic cholinergic receptors, Most likely due to actions of cyclic guanosine monophosphate (cGMP) on intracellular calcium, this result in decreased contractility of smooth muscle.

Used to reduce colonization or prophylactic treatment for localized infection process.Mechanism of Action:Azithromycin binds to the 50S subunit of the 70S bacterial ribosomes, and therefore inhibits

3. Suction Secretions PRN

Collaborative: 1. Check for Chest CT

Scan

2. Take a Specimen for Sputum AFB and Gram Staining Result

RNA-dependent protein synthesis in bacterial cells. Meropenem readily penetrates the cell wall of most Gram-positive and Gram-negative bacteria to reach penicillin-binding- protein (PBP) targets. The bactericidal activity of meropenem results from the inhibition of cell wall synthesis.

3. To facilitate airway clearance

1. To find the cause of lung problem such as DOB and Chest pain.

2. To distinguish presence of infection, identify specific pathogens and influence of the choice of treatment