X.
Problem Prioritization
A. Short Term Objective
After 2 days of nursing interventions the patient will not experience ineffective airway clearance. The complications
brought about by pneumonia will be prevented through proper participation to the different medical and nursing interventions.
B. Problem List
CUES
Subjective cues:
• “Hirap ako huminga dahil ubo
ako ng ubo na my kasamang
plema at minsan my dugo pa.” as to bacterial infection.
verbalized by the patient.
Objective cues:
• Cough with phlegm
• Hemoptysis
• Restless
• Diminished breath sounds
(crackles)
Subjective cues:
• “Hirap ako huminga dahil ubo
ako ng ubo na my kasamang
plema at minsan my dugo pa.” as
verbalized by the patient.
Objective cues:
• Dyspnea
NURSING PROBLEM
Ineffective airway
clearance related to
retained secretions in the
respiratory tract secondary
Ineffective breathing
pattern related to
hypoventilation secondary
to pneumonia
RANK JUSTIFICATION
1  Airway must be given the first attention as based on
the rule of ABC which is Airway, Breathing and
Circulation. In addition, difficulty 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)
2  This demands immediate treatment/care and
subsequent medical attention, as they can result in
ineffective breathing pattern. This also 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
• Alterations of depth of breathing individual has a persistent, unsatisfied need for air
• Use accessory muscles to breath and feel distressed. (Fundamentals of Nursing 8th ed
by Kozier and erb’s p. 549)

Risk for impaired gas 3  This condition needs to be addressed immediately

exchange related to for the patient to be able to give patient awareness
alveolar-capillary about his condition in his body and to be able to
maintain a good gas exchange.
membrane changes
 Lack of attention in this health care problem may
lead to impaired gas exchange which may later
cause bigger threat to the health of the patient.
NURSING CARE PLAN
 Cues Nursing Inference Objective Nursing Rationale Evaluation
Diagnosis
Intervention

Subjective Cues Ineffective Irritant Short Term Goal Independent

airway Assess rate/depth of Frequently present
clearance (inhalation) respirations and chest because of discomfort
movement. of moving chest wall
• “Hirap related to  After 4 hours of and/or fluid in lung.  After 4 hours
ako huminga retained nursing of nursing
dahil ubo ako secretions in Auscultate lung Decreased airflow intervention,
intervention, fields, noting areas of
ng ubo na my the respiratory inflammatory decreased/absent
occurs in areas the goal is met
tract airway patency consolidated with fluid. through
kasamang airflow and
secondary to Response will be adventitious breath
plema at sounds. maintenance of
bacterial maintained,
minsan my
Elevate head of bed,
dugo pa.” as infection. secretions will be change position Lowers diaphragm, airway patency
promoting chest
verbalized by frequently. expansion, aeration of and reduction
the patient. readily lung segments, in congestion.
increase mobilization and
Objective cues: production expectorated and expectoration of
secretions.
• Cough of secretions there will be
with phlegm signs
• hemoptys Assist patient with
is of reduction in frequent deep- Deep breathing
• Restless breathing exercises.
congestion. facilitates maximum
• Diminish airway expansion of the
ed breath
constriction lungs/smaller airways.
sounds
(crackles) Suction as indicated
Stimulates cough or
mechanically clears
airway in patient who
is unable to do so
Dyspnea because of ineffective
cough or decreased
Force fluids to at level of consciousness.
least 3000 mL/day
(unless Fluids (especially
contraindicated, as in warm liquids) aid in
heart failure). Offer mobilization and
warm, rather than expectoration of
cold, fluids. secretions.