Cues Nursing Rationale Goal/Outcome Nursing Rationale Evaluation

Diagnosis Criteria Intervention

1. Ineffective Ineffective After 12 hours of 1. Independent Goal is partially

Subjective airway airway effective nursing a. Assessment met.
“Nabudlaya clearance clearance intervention, the >Assess vital signs, 02 >For baseline data
n sya related to occurs when patient will be saturation After 12 hours
magginhaw secondhand an artificial able to improve of effective
a sa baba” smoking as airway is used airway patency >Perform chest >To encourage nursing
as evidence by because physiotherapy movement of mucus intervention, the
verbalized productive normal Outcome and prevent obstruction patient able to
by the cough, mucociliary Criteria demonstrate
patient’s irregular transport a. noiseless >Elevate head, >To encourage lung improved
mother shallow mechanism is respiration encourage early drainage and prevent airway patency
breaths, bypassed and b. improves ambulation and pooling of secretion and as evidence by
2. Objective tachypnea & impaired oxygen change position prevent vomiting with noiseless
>Productive crackles exchange frequently aspiration into lungs respiration,
cough c. improves vital improved
>Irregular signs within >Indicative of oxygen
shallow normal range >Monitor respirations respiratory distress exchange,
breaths d. absence of and breath sounds, and/or accumulation of improved vital
>Tachypnea productive noting rate and sounds secretions signs within
>Crackles cough normal range.
>Tachypnea, shallow However, the is
Vital signs: >Assess the rate, respirations and still presence of
T- 37.90+C rhythm, and depth of asymmetric chest productive
RR- 44 cpm respiration, chest movement are cough.
PR- 125 movement, and use of frequently present
bpm accessory muscles because of discomfort
SPO2- 92% of moving chest wall
and/or fluid in lung due
to a compensatory
response to airway
obstruction
 >Coughing is the most
>Assess cough effective way to remove
effectiveness and secretions. Pneumonia
productivity may cause thick and
tenacious secretions to
patients

>Increasing the
>Use humidified humidity will decrease
oxygen at bedside the viscosity of
secretions

>To clear airway

>Suction nose, mouth, when excessive or
and trachea prn using viscous secretions are
correct size blocking airway
catheter and suction or client is unable to
timing for child swallow or cough
effectively

> This may compromise

>Monitor child for airway
feeding intolerance,
abdominal distention,
and emotional
stressors
>Hydration can help
> Increase fluid intake prevent
to at least 2,000 the accumulation of
mL/day within cardiac viscous secretions and
tolerance improve secretion
clearance

>To ascertain current

> Auscultate breath status and note effects
sounds and assess air of treatment in clearing
movement airways

> Pharmacological
> Document response therapy is used to
to drug therapy and prevent and control
development of symptoms, reduce
adverse side effects severity of
medication exacerbations, and
improve health status

b. Health Teachings -To maximize effort

> Encourage deep-
breathing and
coughing exercises or
splint chest/ incision
-To enhance ventilation
>Instruct parents to to different lung
change position segments
frequently
> Smoking is known
>Advice parent to urge to increase production
reduction of parent of mucus and to
smoking paralyze (or cause
loss of) cilia needed to
move secretions to
clear airway and
improve lung function

>Advice parents to > This reduces fatigue

encourage on child
opportunities for rest;
limit activities to level
of respiratory tolerance

2. Dependent
 >Administer IV fluid
therapy as ordered - Fluids are required to
replace losses,
including insensible
losses, and aid in
mobilization of
secretions
> Administer
analgesics as ordered >To improve cough
when pain is inhibiting
effort
>Administer
medications as > to relax smooth
ordered respiratory musculature,
reduce
airway edema, and
3. Collaborative mobilize secretions
>Collaborate to
nutritionist in diet for >To promote proper
age of patient nutrition appropriate for
the patient

Cues Nursing Rationale Goal/Outcome Nursing Rationale Evaluation

Diagnosis Criteria Intervention

1. Ineffective Pneumonia is After 4 hours of 1. Independent Goal is met.

Subjective breathing an infection effective nursing a. Assessment
“Nabudlayan pattern and intervention, the >Assess vital signs, 02 >For baseline data After 4 hours of
sya related to inflammation patient will be saturation effective
magginhawa presence of of alveoli. able to nursing
kung secretion as Presence of demonstrate > Assess the rate, > Tachypnea, shallow intervention, the
gahigda” as evidence by secretion in proper breathing rhythm, and depth of respirations and patient able to
verbalized productive the bronchi technique respiration, chest asymmetric chest demonstrate
by the cough, will result movement, and use of movement are proper
patient’s irregular blockage of Outcome accessory muscles frequently present breathing
mother shallow air and Criteria because of discomfort technique as
breaths, changes in a. clear breath of moving chest wall evidenced by
2. Objective tachypnea, breathing sounds and/or fluid in lung due clear breath
>Productive use of pattern occur b. demonstrates to a compensatory sounds,
cough accessory because effective response to airway demonstrated
>Irregular muscle to affected coughing obstruction effective
shallow breath & alveoli cannot c. absence of coughing,
breaths decreased effectively dyspnea >Auscultate and >Abnormal breath absence of
>Tachypnea breath exchange d. improves vital percuss chest, sounds dyspnea and
>Use of sounds oxygen and signs within describing presence, are indicative of improved vital
accessory carbon normal range absence, and numerous problems signs within
muscles to dioxide character of breath and must be normal range
breathe sounds evaluated further
>Decreased
breath >Perform chest >To encourage
sounds physiotherapy movement of mucus
and prevent obstruction
Vital signs:
T- 37.90+C > Elevate the head of >To promote
RR- 44 cpm the bed or have the physiological and
PR- 125 client sit up in a psychological ease of
bpm chair, as appropriate maximal inspiration
SPO2- 92%
>Suction airway, as >To clear secretions
needed

>Observe > May see use

characteristics of of accessory muscles
breathing pattern for breathing, sternal
retractions in young
children, nasal flaring,
or pursed lip breathing.
Irregular patterns
 (prolonged expiration,
periods of apnea,
obvious agonal
breathing)
may be pathological

>Monitor pulse >To verify maintenance

oximetry, as indicated or improvement in O 2
saturation.

>Assess for >It may restrict

concomitant respiratory effort
pain/discomfort

b. Health Teachings
>Teach patient slower >It allows patient to
and deeper participate in
respirations and use of maintaining health
the pursed-lip status and improve
technique ventilation.

>Encourage parents to >To prevent crowding of

serve small frequent the diaphragm
meals

2. Dependent
>Administer IV fluid > Fluids are required to
therapy as ordered replace losses,
including insensible
losses, and aid in
mobilization of
secretions

> Administer oxygen at >To help labored

the lowest breathing and prevent
concentration as hypoxemia
 ordered

>Administer analgesics >to promote deeper

as ordered respiration and cough

3. Collaborative
>Collaborate to >PCAP may cause
nutritionist in diet for malnutrition which can
age of patient affect breathing pattern.
Good nutrition can
strengthen the
functionality of
respiratory muscles

Cues Nursing Rationale Goal/Outcome Nursing Rationale Evaluation

Diagnosis Criteria Intervention
1. Risk for Pneumonia is After 8 hours of 1. Independent Goal is met.
Subjective infection an effective nursing a. Assessment
“Nahilanat sa related to inflammation intervention, the > Assess patient’s > Immunizations with After 8 hours of
kag galingin inadequate of alveoli that patient will be immunization status pneumococcal vaccine effective
iya ulo nga vaccination, impair gas free from further and seasonal influenza nursing
daw masuka’ malnutrition exchange and infection are used to reduce the intervention,
as verbalized and cause by the risk for developing the patient is
by the secondhand patient’s Outcome pneumonia. free from
patient’s smoking inhaling or Criteria further infection
mother aspirating a a. absence of >Assess vital signs, >Provide information as evidenced
pathogen. It is fever WBC and auscultate about the spread of by absence of
2. Objective also caused b. improves breath sounds infection, increased RR fever, improved
>underweight by the spread WBC within and PR, high WBC are WBC within
of bacteria normal range signs of sepsis. Spread normal range,
Vital signs: from an c. improves vital of infection may cause & improved
T- 370C infection signs within respiratory distress vital signs
RR- 44 cpm elsewhere in normal range within normal
PR- 125 bpm the body. >Observe at-risk client >Changes could range
SPO2- 92% for changes in color indicate onset of
WBC- 14,000 and odor of sputum, infection
drainage and excretion

>Practice and
emphasize constant
and proper hand >Hand washing
hygiene prevents the spread of
pathogens from patient
> Encourage early to nurse and vice versa
ambulation, deep
breathing, coughing, > for mobilization of
position changes respiratory secretions
and prevention of
aspiration/respiratory
>Monitor vital signs infections
closely, especially
during initiation of > During this period,
therapy potentially fatal
complications, such as
hypotension or shock,
>Investigate sudden may develop
change in condition,
such as increasing > Delayed recovery or
chest pain, extra heart increase in severity of
sounds, altered symptoms
sensorium, recurring suggests resistance to
fever, changes in antibiotics or secondary
sputum characteristics infection

>Monitor effectiveness
of antimicrobial
therapy
> Signs of improvement
b. Health Teachings in condition should
>Encourage adequate occur within 24 to
rest balanced with 48 hours
moderate activity
> Facilitates healing
>Promote adequate process and enhances
nutritional intake and natural resistance
diet for age
> Facilitates healing
>Advice parents to process and enhances
limit visitors natural resistance

>To reduce likelihood of

exposure to other
2. Dependent infectious
>Administer antibiotics pathogens
as ordered

>Antibiotics act to
inhibit the growth of
 bacteria and destruction
of bacteria. These
drugs are used to
combat most of the
microbial
pneumonias.
Combinations of drugs
can be used when
the pneumonia is a
>Administer oxygen as result of mixed
ordered organisms.

>Respiratory support
may be needed during
the acute phase of
infection to prevent
>Administer IV fluid as additional physiological
ordered stress

3. Collaborative >IV fluids help maintain

>Assist with additional fluid balance
diagnostic studies, as
indicated.
>Further diagnostic
studies may prevent
further infections