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Assessment Objective: > Crackles noted upon auscultation on both lungs.

> productive cough noted with whitish sputum > use of accessory muscles

Diagnosis Ineffective airway clearance related to retained secretions on the bronchial airway secondary to pneumonia.

Rationale Inability to clear secretions or obstructions from th respiratory tract to maintain clear airway

Planning At the end of the nursing interventions during the 8 hour shift, patient will be able to: - Maintain patent airway. -Demonstrate absence /reduction of congestion with breath sounds clear

Interventions - Place client in semi-fowlers position. - Change position of the client every 2 hours and as needed.

Rationale - To promote maximum lung expansion.


Goal is partially met. At the end of the nursing interventions - To take during the 8 hour advantage of shift, the client has gravity decreasing a patent airway pressure on the but still with diaphragm and excessive amount enhancing of secretion. ventilation to different lung segments. - to mobilize bronchial secretion to larger airways. - to remove secretions in the bronchial airway to promote proper breathing.

- perform Chest physiotherapy.

- Suction secretions as needed.

- Keep bedside clean and allergen free.

- to reduce irritant on airway.

Objective: - GCS= 7 (E-2;V4;M-1) -Constricted pupils, sluggish reaction to light. -LOC: stuporous

Ineffective cerebral tissue perfusion related to hemorrhage secondary to CVD.

Decreased reabsorption of blood, CSF, fluid in the brain back to the hear Continuous flow of subarachnoid blood and CSF in the brain and brain stem Clot formation in the arterioles in the brain ICP Compression of the brain Ischemia / signs of cyanosis. Patching in the subarachnoid space

At the end of the nursing interventions during the 8 hour shift, patient will be able to: - Maintain usual/improved LOC - Display no further deterioration /recurrence of deficits

-Assess neuro vital signs hourly.

- to closely monitor change in LOC. -Position with -to reduce arterial head elevated and pressure by in neutral promoting venous position. drainage and may improve cerebral circulation/perfusi on. -Continual stimulation/activit y can increase -Maintain bed ICP, absolute rest rest, provide quiet and quiet environment, environment provide rest may be needed to periods between prevent bleeding care activities, and -Indicative of limit duration of meningeal procedures. irritation, especially in -Assess for nuchal hemorrhagic rigidity, twitching, disorders. increase Seizures may restlessness, reflect increase irritability, onset ICP. of seizure activity. - reduces hypoxemia which can cause cerebral vasodilation and - administer O2 increase

Goal is not met. Clients LOC is not improved and deterioration is evident.

via tracheotomy

pressure/edema formation. - to promote optimal level of functioning and prevent complications. - to promote circulation and prevent contractures. - promotes wellbeing and maximizes energy. Goal is not met. The client is not able to improve strength and cant move by herself

Impaired physical mobility related to - Deteriorated neuromuscular muscle strength and impairment control secondary to cerebrovascular - Generalized body disease. weakness Objective:

Limitation in independent, purposeful physical movement of the body or of one or more extremities.

At the end of the nursing interventions during the 8 hour shift, patient will be able to: - improve strength

- reposition client on regular schedule as dictated by individual situation - peform passive range of motion.

- Encourage adequate intake of fluids/nutritious foods.