University of the Philippines Manila

Health Sciences Center

COLLEGE OF NURSING
Sotejo Hall, Pedro St., Ermita, Manila
NURSING 11
NURSING CARE PLAN
Student: Lee, Kim Gabrielle Exene C.
Client: Racelis, Maria Tenolete
Medical Diagnosis: Pneumonia in the immunocompromised patient, AML in blast crisis
CUES
Subjective cues:
The client stated
she is not able to
expectorate, Di
ko alam, di ko
kasi mailabas.
Sabi sa x-ray
may plema, pero
wala naman
akong nalalabas.
The client
verbalized
feeling of the
presence of the
secretions on her
airways Meron
akong
nararamdaman na
parang may
plema sa
lalamunan ko.
The client
verbalized,
Sinusubukan
kong umubo ng
pasadya para
lumabas, kaso

NURSING
DIAGNOSIS
Ineffective airway
clearance related
to retained
secretions

BACKGROUND
KNOWLEDGE
Ineffective airway clearance
is the inability to clear
secretions or obstructions
from the respiratory tract to
maintain a clear airway.

GOAL AND
OBJECTIVES
At the end of nursing
intervention, the client
will be able to:
Goal:
> Client will be able to
maintain adequate,
patent airway.

Relating to the client, she is

not able to expectorate well
even though there is the Objectives:
presence of secretions on her
Client will state the
airway.
benefits of having a
clear, patent airway
Hospital-acquired pneumonia
(HAP)
or
nosocomial
pneumonia
refers
to
any pneumonia contracted by
a patient in a hospital at least
4872 hours after being
admitted. The client has been
staying at PGH for about 13
days.

INTERVENTIONS AND
RATIONALE
Assess physical health level and
potential injuries and/or illnesses.
This will serve as a basis to avoid
worsening the clients condition
after the interventions.

Health Teaching: Importance of

clear, patent airway.
Rationale: In this way, the client
will have background knowledge
about the importance of patent
airway and be motivated to
maintain a patent airway.

Older adults may have

different, fewer, or milder
symptoms, such as having no
fever or having a cough with
no mucus (a dry or
nonproductive
cough).

Date of Assignment: April 5, 2016

Sex: F
Civil Status: Married

Age: 77 y/o

Provision of enough
ventilation for the whole
body
Breath with ease without the
use of accessory muscles
Relieve shortness of breath
and difficulty breathing
Relieve chest pain
Prevent worse progression
of lung condition

EVALUATION
Standard
Criteria

The client will States at least 3

state the benefits
benefits of
of having a clear,
having a clear,
patent airway
patent airway

hindi lumalabas
ang plema.

The client
verbalized loss of
appetite.

Objective cues:
Diagnosed with
Hospital-acquired
pneumonia.
Lower right lung
is full of
secretions as
shown on recent
chest x-ray.
Use of accessory
muscles for
breathing.
Low energy,
fatigue
In need of O2
support.
RR at rest on
bed: 26
Positive for rales

Dyspnea and fatigability of

client are taken as symptoms
of HAP. The degree of
dyspnea is not solely because
of anemia as shown on the
clients blood test. There is
increased desaturation even
after blood transfusion.
Acute myeloid leukemia
(AML)also known as acute
nonlymphocytic
leukemia
(ANLL)is
the
most
common form of adult

leukemia. Most patients are

of retirement age (average
age at diagnosis is 65 years),
and more men are affected
than women. AML begins
with abnormalities in the
bone marrow blast cells that
develop to form granulocytes,
the white blood cells that
contain small particles, or
granules. The AML blasts do
not mature, and they become
too numerous in the blood
and bone marrow. As the cells
build up, they hamper the
body's ability to fight
infection
and
prevent
bleeding. Therefore, it is
necessary to treat this disease
within a short time after
making a diagnosis. Blast
phase (acute phase, blast
crisis)Patients in this final
phase have more than 30
percent blast cells in their
blood and bone marrow
samples. The blast cells

Circulate blood
Deliver enough oxygen to
the whole body
Avoid greater risk for
infections

Client will be able to Health Teaching: Consequences

describe
of retained secretions
consequences of
Rationale: In this way, the client
retained secretions.
will be motivated to avoid these
disadvantages and maintain a
patent airway.
Client will be able to Health Teaching: Hydration for
discuss the role of
airway clearance
hydration in
Rationale: This is to motivate the
maintaining a clear
client to drink more water.
airway.
Drinking a lot of water
that can facilitate
expectoration by
loosening the
secretions.
Client will be able to Demonstrate deep breathing
perform correct deep
exercises.
breathing exercises.
Rationale: This will increase the
clients capability to breathe at
ease.
Client will be able to Position head of client
mobilize secretions.
appropriate for condition.
Rationale: To open or maintain
open airway.

The client will

enumerate
consequences of
retained
secretions.

Enumerates at least
2 consequences
of retained
secretions.

States drinking a
lot of water will
The client will be
help loosen the
able to determine
secretions.
the role of
hydration in
maintenance of
clear airway.

The client will

perform deep
breathing
exercises
correctly.
The client will
verbalize
comfortable
positioning.

The client will

identify the
Turn client to opposite side every
different
2 hours
techniques and
Rationale: To take advantage of
range of motion

Demonstrates deep
breathing
exercises
correctly.

Verbalizes being
comfortable to
position.

The client will

demonstrate at
least 3 of the
range of motion
exercises
appropriate for

frequently
invade
other
tissues and organs outside of
the bone marrow. During this
phase, the disease transforms
into an aggressive, acute
leukemia (70 percent acute
myelogenous leukemia, 30
percent acute lymphocytic
leukemia).

References:
- Carpenito, L. J. (2009).
Nursing diagnosis:

Application to Clinical
Practice .Philadelphia:
Wolters Kluwer
Health/Lippincott Williams &
Wilkins.
- Mayo Clinic (2015). Acute
Myelogenous Leukemia.
Retrieved from
http://www.mayoclinic.com/
- Mayo Clinic (2016).
Pneumonia. Retrieved from
http://www.mayoclinic

gravity decreasing pressure on the

diaphragm and enhancing drainage
of ventilation to different lung
segments.

Perform chest physiotherapy

preferably after nebulization.
Rationale: Chest physiotherapy
loosens the secretions. IT is best to
do this after nebulisation because
the alveoli are still open, thus
secretions can easily come out.

exercises
her.
discussed and
demonstrated by
Expectorates
the nurse.
The client will be
effectively after
able to
CP.
expectorate after
CP.

The client will be

able to
demonstrate
Client will be able to Demonstrate specific airway
proper airway
expectorate/clear
clearance techniques.
clearance
secretions readily.
Rationale: With this, the client will
techniques.
be able to perform airway
clearance techniques by herself and
do it correctly.
The client will
verbalize relief
from airway
Suction naso/tracheal/oral prn
obstructions.
Rationale: To clear airway when
excessive or viscous secretions are
blocking airway or client is unable
to swallow or couh effectively.

Demonstrates
proper airway
clearance
techniques.

Verbalizea relief
from airway
obstructions.