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Assessment Subjective:





Evaluation After 2 days of nursing intervention, the patient displayed time healing of pressure sores.

Impaired skin Within 2  Assessed tissues,  For comparative integrity days of bony prominences, baseline data “naaawa na ko and pressure areas related to nursing sa kapatid ko, physical intervention,  Assessed adequacy  To assess degree of ang dami na nya immobilizatio the patient of blood supply and impairment kasi bed sores innervations of the n as will display eh” as tissue on the sole manifested by timely facilitate verbalized by part of the right foot  To the presence healing of healing.  Promoted optimum the patient’s of pressure pressure nutrition with highbrother sores sores quality protein and without sufficient calories, complicatio vitamins, and ns Objective: mineral Inference  Disruption of skin surface/ presence of wound on lower back  Redness around wounds  Physical immobilizatio n  VS: -abyss wala ako copy ng vs at gcs niya Tsaka pla palagay nalang kung gano na sya katagal sa hosp. Di ko alam eh, sorry physical immobilizatio n


friction on lower back (sacral part)

supplements promote  Strictly follow the  To circulation and implementation and prevent excessive posting of a turning tissue pressure schedule, restricting 2 hours or less and time in one position to customizing the schedule to patient’s routine.  Practiced aseptic  To reduce the risk for crosstechnique for contamination cleansing/dressing/ medicating lesions  To see changes  Monitored indicative of laboratory values. healing/infection/ complications.

redness on skin

disruption of skin surface

Tissue damage/eru ption of skin


Diagnosis Ineffective airway clearance related to retained secretions

Planning Within 2 days of nursing intervention, the patient will demonstrate absence/ reduction of congestion with breath sounds clear, respiration noiseless, improve oxygen exchange



Evaluation Within 2 days of nursing intervention, the patient demonstrated absence/ reduction of congestion with breath sounds clear, respiration noiseless, improved oxygen exchange as


“ang daming secretions na lumalabas sa bibig at tracheostomy ng kapatid ko.”, as Inference verbalized by physical the patient’s immobilizatio brother.

 Assess patient’s  To gain the trust and cooperation condition Monitor and record V/S  Auscultate lung  To know and fields, noting areas determine patient’s needs. To identify of decreased/absent areas of airflow and consolidation and adventitious breath determine possible sounds bronchospasm or obstruction.  Assist patient to  To mobilize change position secretions every 30 minutes  Elevate head of bed  To facilitate and align head in breathing the middle


 Crackles, upon auscultatio inability to n, on both expel lungs secretions  Ineffective / absent cough extensive  Excessive obstruction sputum airway  RR O2 satineffective airway clearance

retained secretions

manifested by:

RR: remove  Suction every 2  To O2 sat: obstructed mucus hours or as necessary  Administer meds as  To reduce ordered. bronchospasm and mobilize secretion Nebulisation of combivent every 8 hours

1. Ineffective Airway Clearance NDx: Ineffective airway clearance related to presence of secretions secondary to pneumonia. The inflammation and increased secretions make it difficult to maintain a patent airway, which is cause by decrease ability to expel the excessive mucus produced that will lead to extensive obstruction of the airway.

Read more at 5 Pneumonia Nursing Care Plans

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