C.

NURSING PROBLEM PRIORITIZATION

PRIORITIZATION DIAGNOSIS JUSTIFICATION

Problem No. 1 Ineffective Airway Clearance  Airway must be given the first attention as based on the rule of
ABC which is Airway, Breathing and Circulation. In addition, difficulty
1 of breathing can cause anxiety to the client that is why, immediate
attention must be done. Addressing the problem to proper health care
provider will give patent airway to the client. Oxygenation is a vital
need for every cell, if there are any problems related to it can easily
affect the functioning of the individual. Retained secretions can cause
blockage of airway which will further cause difficulty of
breathing(Fundamentals of Nursing 8th ed by Kozier and erb’s p. 1299

Problem No. 2 Impaired Gas Exchange  Lack of action in this health care problem may cause leading to
hypoxia of the lung tissue and a significant ventilation-perfusion
2
mismatch

Problem No. 3 Ineffective Breathing Pattern  This demands immediate treatment/care and subsequent medical
attention, as they can result in ineffective breathing pattern. This also
3 needs attention as based on the rule of ABC which is Airway, Breathing
and Circulation. This is an actual problem that needs to address.
 Lack of action in this health care problem may cause dyspnea which
may later cause a bigger threat to the health of the patient.
 Difficult and labored in breathing during which the individual has a
persistent, unsatisfied need for air and feel distressed. (Fundamentals
of Nursing 8th ed by Kozier and erb’s p. 549)

4 Problem No. 4 Hyperthermia  CAP is the inflammation of the lung parenchyma due to offending
organisms, inflammatory lung response will be stimulated leading to
 the release of chemical mediators that would increase blood flow to
the lung tissues leading to erythema, swelling, pain, and increased body
temperature that would reset the hypothalamus which is the major
center for regulation of body temperature
Problem No. 5 Activity Intolerance  The onset of pneumonia is generally marked by fever, dyspnea, and
5 shortness of breath and easy fatigability that may lead to inability to
perform activities of daily living

Problem No. 1 Ineffective Airway Clearance

Assessment Nursing Diagnosis Scientific Planning Nursing Rationale Evaluation

Explanation Intervention

Subjective Cue: Ineffective Airway Community- Short Term : > Assess respiratory > Abnormal breathing Short Term :
Clearance related to Acquired status: breath patterns may signal
“nahihirapan siyang retained secretions in Pneumonia is the sounds, respiratory worsening of condition:
huminga dahil sa plema the bronchi ( inflammation of the After 5 hours rate, oxygen flaring of nostrils
yun yung sinabi sa akin The patient shall be
increased thick lung parenchyma of Nursing saturation, note indicate a significant able to expectorate
nung nars” as verbalized mucous secretions) when the offending Interventions, abnormalities such decline in respiratory
by the mother. mucous as evidenced
and lung organism reaches the patient will as dyspnea, presence status: assessment by productive cough
inflammation the alveoli via expectorate of cyanosis, use of establishes baseline and effective coughing
leading to droplets or saliva in mucous as accessory muscles, monitor response to and breathing
accumulation of whi8ch goblet cells evidenced by flaring of nostrils interventions exercise
mucous in the produces an productive
Objective cues :
alveoli outpouring fluid into cough,
the alveoli. The effective > Assess anxiety
organisms multiply coughing and and reassure patient
 >appears weak in the serous fluid breathing ć presence > Being unstable to
and the infection is exercise breath causes anxiety
spread. The and fear: the patient
>pale palpebral organisms damage needs a calming
conjunctiva the host by their presence: anxiety
overwhelming increases the demand
growth and Long Term : for oxygen
Long Term :
interference with
>ć rales on both lung
lung function > Place patient in
lobes upon chest
auscultation
leading to massive After 2 days of high fowler’s > Maximize chest
accumulation of Nursing position and support The patient will
excursion and
mucus. Disruption Interventions, ć overbed table as maintain airway
subsequent movement
of the mechanical the patient will needed. patency as evidenced
of air
>ć difficulty of breathing defenses of cough maintain by clear breath
and ciliary motility airway sounds, absence of
leads to the patency as dyspnea, etc.
> Encourage
> shortness of breath colonization of the evidenced by expectoration of
lungs and clear breath secretions and
accumulation of sounds, assess the viscosity > Thickened secretions
> ć non- productive secretions in the absence of amount and color of of Cap re more likely to
cough alveoli and bronchi dyspnea, etc. secretions occlude the airway:
leading to
ineffective airway making this observation
clearance as would allow for
evidence by non- implementation if
productive cough measures to thin and
etc. alveolar loosen the secretions
>Tachypnea exudates tend to
consolidate,
>Restlessness increasingly difficult > Assist the patient > Mobilizes secretions
to expectorate. ć coughing and deep and prevent atelectasis
breathing
> ć Orthopnea

> Increase fluid

intake > Assists with
> Flaring of nostrils liquefying secretions
and enhancing ability to
clear airways

> Decrease demand for

oxygen
> Provide for
periods of rest and
activity, assisting ć
devices as needed

> Elevate head of

bed/ change of
position every 2 > To maintain an open
hours airway and to take
advantage of gravity
decreasing pressure on
the diaphragm and
enhancing drainage of
 secretions.

>This causes
bronchiodilation to ease
> Assist respiratory breathing
therapist ć the
administration of
nebulizer

> Ensures a route for

> Establish rapid- acting
intravenous access medications
as ordered

> Assess arterial

blood gases (ABG) >ABG provide data for
treatment regarding the
lungs’ ability to
oxygenate tissues

> Loosen secretions,

> Provide making them easier to
humidified oxygen expectorate ć coughing:
as ordered to improves oxygenation
maintain O2
 saturation >90%

Problem No. 2 Impaired Gas Exchange

Assessment Nursing Scientific Planning Nursing Rationale Evaluation

Diagnosis Explanation Intervention

Subjective Cue: Impaired Community- Short Term : > Perform a > Because airway Short Term :
Gas Acquired complete inflammation and
“Pansin ko lagi Exchange Pneumonia is respiratory mucous accumulation, The patient shall
siyang parang related to defined as a lower assessment ; pneumonia can cause be relieved from
hinihingal” as After 8hours dyspnea by
 verbalized by the inflamed respiratory tract of Nursing respiratory rate, fluid in the lungs and participating in
mother lung tissue infection of the Interventions, rhythm, chest increase the work of breathing
and lungs parenchyma the patient expansion, ease of breathing, resulting in exercise, effective
consolidatio with onset in the will be breathing, use of impaired gas exchange. coughing and use
n of mucous community or relieved from accessory muscles, These assessment of oxygen as
/ ffluid in during thre first dyspnea by pursed lip provide data use for evidenced by
Objective cue : specific 2days of participating breathing, breath planning absence of nasal
lung lobes hospitalization. in breathing sounds, mucous flaring, shortness
preventing Pneumonia occurs exercises, expectoration, Interventions and of breath, easy
transfer of when the offending effective perioral cyanosis, assessing progress. fatigability. Etc.
>difficulty of
gases across organism stimulate coughing and tachypnea, dyspnea, Sputum cultures identify
breathing
the alveolar inflammatory use of oxygen pulse oximetry and the causative organisms,
capillary response the as evidenced monitor laboratory arterial blood gases
cellular defense mechanism by absent of and diagnostic demonstrate decreased
>nasal flaring oxygen concentration,
membrane of the lung lo9se nasal flaring, procedures such as
effectiveness and shortness of sputum cultures, chest x-ray will confirm
allow organisms to breath, easy complete blood the presence of fluid in
>shortness of breath/ penetrate the sterile, fatigability, count, arterial blood the lungs or areas of
Long Term :
exertional lower respiratory etc. gases, etc. consolidation
discomfort tract, where
inflammation
The patient shall
develops. > Obtain subjective have an improved
>with presence of Inflammation data from the ventilation and
crackles on both occurs due to Long Term : patient or adequate
lung lobes upon colonization of significant other, > knowledge of the oxygenation of
auscultation offending including history of patient respiratory status lung tissue as
organization After 1 to 3 chronic respiratory contributes to evidenced by
wherein there is the days of disease and history information that can normal arterial
> with non release of chemical Nursing assist in determination blood gases, clear
productive cough mediators, Interventions, of smoking other factors that may Breathing sounds,
attraction of the patient have contributed to absence of
neutrophils, will have an pneumonia or influence purulent
> easy fatigability accumulation of improved > Assist patient to its treatment discharges, etc.
fibrinous exudates, ventilation semi fowler’s
red blood cells and and adequate position
macrophages. oxygenation > Sitting upright allows
>Tachycardia
These would in turn of lung tissue the diaphragm to
trigger erythema as evidenced descend, resulting in
swelling, edema by normal easier breathing
> abnormal rate and stimulation of arterial blood >Take temperature
rhythm, depth of nerve fibers, gases, patient every 4 hours
breathing leading to pain. will have a
> Infectious processes
Goblet cells will clear breath
can cause an increase
increase mucus sounds,
body temperature
production in absence of
attempt to dilute purulent > Provide comfort
>Restlessness amd wash away discharge measures change
offending linen or clothing >Following temperature
organisms out of spikes, linen and
>Confusion the respiratory tract. clothing may become
Inflamed fluid-filler saturated with
alveolar sacs cannot perspiration
>fever exchange O2 and
CO2 effectively
leading to hypoxia > Helps thin and liquefy
of the lung tissue > Encourage secretions
 O
and a significant adequate fluid
2
ventilation- intake to 2000
 perfusion mismatch cc/day
s
a
t > Assess mucous >Helps to detect
u amount, color improving status of
r consistency. pneumonia, amount
a should be decreasing
t and viscosity should be
i thinning following
o interventions; green,
n brown or purulent
mucus indicate
o continued presence of
f pneumonia
l
e
s
>Coughing and deep
s
breathing cause alveoli
to open and loosen
t
mucous to help clear the
h
airways
a
>Encourage
n
coughing and deep
breathing with
9
mucous
0
expectoration >Loosen mucous plugs
%
thus increasing are
 available for gas
 exchange

> Provide chest

physiotherapy
postural drainage,
chest percussion
and vibration
> To maintain airway
patency
> Elevate head of
bed
>Promotes optimal chest
expansion and drainage
> Encourage of secretion
frequent position
changes
> Helps limit oxygen
needs/ consumption
> Encourage
adequate rest and
limit activities to
with in patient
tolerance. Promote
calm and restful
environment

> Administer
oxygen as ordered

>Pneumonia increased
mucous production and
fluid retention in lungs
which decreases
adequate gas exchange;
supplemental oxygen
provides additional
oxygen for tissue
oxygenation

>Helps to stop the

proliferation of
microorganisms
>Administer
antibiotic as
ordered and
monitor for side
effects.

 A
d
o
 Problem No. 3 Ineffective Breathing Pattern

Assessment Nursing Scientific Planning Nursing Rationale Evaluation

Diagnosis Explanation Intervention
 Subjective Ineffective Community- Short Term : > Assess > Any of this Short Term
Cue: breathing Acquired is a respiratory system abnormalities would :
pattern disease process by noting indicate the studies of
“Nahihirapang related to involving respiratory rate, the respiratory system
huminga ang After 4 hours
thick inflammation of of Nursing depth chest and progression of The patient
baby ko.”, as tenacious lung tissue. It expansion, breath disease; also
verbalized by Interventions, shall have a
secretions in typically results the patient sounds, arterial establishes a baseline normal
the mother the bronchi when blood gases, etc. comparison
shall have a respiratory
due to microorganisams normal rate, rhythm,
inflammatio enter the normally respiratory depth of
n of lung sterile lungs from rate, rhythm, >maximizes thoracic breathing and
tissue the nasopharynx depth and cavity space, decreases relief from
O=Patient > Assist Patient in
and produces reports a pressure from shortness of
Manifested assuming a high-
inflammation of the shortness of diaphragm and breath as
the following : fowler’s position or
lung parenchyma. breath as abdominal organs and evidence by
Because of the evidence by position of choice facilitates use of decrease RR
inflammation of the decrease RR such as leaning accessory muscles from 38 cpm
>difficulty of alveoli are filed forward or over bed
from 38 cpm to 16-20 cpm
breathing with fluid and table
to 16-20 cpm
mucus and oxygen
>help to improve
and carbon dioxide
hydration status and
>shortness of exchange cannot > Increase oral decrease secretions.
breath on take place at a fluids to 2000-3000
exertion, alveolar capillary Long Term : ml/day as tolerated
paleness cellular membrane
level due to blood
flow decreases
After 2 days > Provide chest > mobilizes thick
 > ć non- (deceased perfusion of Nursing physiotherapy, secretions, and
productive of blood in the Interventions, bronchial tapping, facilitates clearing of
cough lungs)and the patient vibration, etc. lung fields.
leukocytes and shall be free Long Term :
fibrin consolidate in from any
> with the affected part of signs and >Assist with The patient
presence of the lung due to a symptoms of activities of daily shall be free
rales on both decreased blood hypoxia as living as required >patient with from any
lung lobe upon flow there is a evidenced by pneumonia may lack signs and
chest decreased supply of normal ABG, sufficient oxygen symptoms of
auscultation oxygen to other etc. reserves to perform hypoxia as
easily tissues leading to activites; even eating evidenced by
fatigability ineffective may cause severe normal ABG,
breathing pattern dyspnea etc.

>severe
dyspnea > Knowing how to
> Teach patient control shortness of
how to decrease breath will help cope
shorthness of breath and have optimal
by restructuring functioning
activities

>Teach pulmonary
hygiene; prevention > Preventing spread of
of spread of infection and
infection subsequent
 hospitalization

>Provide
humidified low
flow of oxygen as
ordered

>Provide some
supplemental oxygen to
improve oxygenation
and to make secretions
less viscous
>Administer
bronchodilators and
expectorants
>Enhances
expectoration of
secretions of previously
ineffective cough

> Administer >Helps to prevent or

antibiotics as eradicate infections to
ordered reduce secretions and
to end to inflammation