c. Nursing Care Plan Ineffective Airway Clearance r/t accumulation of tracheobronchial secretions Assessment Planning Nursing Intervention Rationale Expected Outcome/Evaluation
Restlessness/i rritability Nasal flaring Rales on both lungs Tachypnea with RR 62bpm Tachycardia with 204 bpm DOB Cough Presence of secretion Short term: After 3-4 hours of NI pt. will be able to demonstrate Airway clearance, reduction of secretion, RR improve. Long term: After 2-3 days of NI pt. will be able to establish and maintain airway patency monitor /record vital sign assess patient condition elevate head and encourage frequent position changed keep back dry and loosen clothing Instruct S.O. to provide an increase fluid intake for the child Instruct S.O. to provide adequate rest periods for the child Give Expectorant and bronchodilator To obtain baseline data To know patient general condition To promote and improve ventilation To promote comfort and adequate ventilation To liquefy the secretions Rest will prevent fatigue and decrease oxygen demand to further mobilize the secretions To clear airway when secretions are blocking To indicate increase oxygen saturation Short term: After 3-4 hours of NI pt. shall have demonstrated improve airway clearance reduction of congestion with clear breath sounds and Improve RR Long term: After 2-3 days of NI pt. shall have established and maintain airway patency MEDICAL CENTER IMUS Diversion Road, Palico IV, Imus, Cavite 4103
s as ordered Administer oxygen and bronchodilator s as ordered Provide suctioning as ordered
MEDICAL CENTER IMUS Diversion Road, Palico IV, Imus, Cavite 4103
Impaired Gas Exchange r/t accumulation of sputum affecting O2 and CO2 transport Assessment Planning Nursing Intervention
Rationale Expected Outcome/Intervention Restlessness Irritability DOB Cough Nasal flaring Chest in drawing Tachypnea Presence of secretion
Short Term: After 6 hours of NI pt. will be able to demonstrate improve in gas exchange Improve respiratory rate to normal
Long Term.: After 1-2 days of NI pt. will be able to demonstrate improved ventilation and adequate oxygenation of tissue absence of symptoms of respiratory distress. Monitor v/s Elevate head and encourage frequent position changed Keep back dry Promote adequate rest periods Change position every 2 hours Keep environment allergen free Suction secretion PRN Instruct patient to increase fluid intake of the child Administer oxygen therapy as ordered To obtain baseline data To promote maximal inspiration enhance expectoration of secretions in order to improve ventilation To avoid coughing Rest will prevent fatigue and decreased oxygen demand To promote drainage of secretion To reduce irritants effects on airways To indicate to increase oxygen saturation O2 therapy is indicated Short term: Patient shall demonstrate improvement in gas exchange a decrease in respiratory rate to normal
Long term: Patient shall demonstrate Improved ventilation And adequate oxygenation of tissue absence of symptoms of respiratory distress
MEDICAL CENTER IMUS Diversion Road, Palico IV, Imus, Cavite 4103
increase O2 saturation.
MEDICAL CENTER IMUS Diversion Road, Palico IV, Imus, Cavite 4103
Disturbed Sleeping Pattern r/t Difficulty of Breathing Assessment Planning
Nursing Intervention Rationale Expected Outcome/Evaluation Irritability Restlessness DOB Nasal flaring Patient may manifest lack of interest in breastfeeding tachypnea Short term:After 3 hours of nursing intervention the parents will be able to verbalize understanding of sleep disturbance and identify interventions to promote sleep for the child Long term: After 3 days of Nursing Intervention parent will be able to report improvement in sleep pattern of the child monitor v/s encourage parent to increase intake of milk for the child provide quiet environment for the child instruct parent to provide dim environment for the child advise parent to provide warm/cotton blanket for the child instruct parent to elevate the head of the child
to obtain baseline data to promote relaxation sleep periods for child to promote comfort and chills for the child to maximize lung expansion of the child and to prevent DOB
Short Term: After 3 hours of NI the parent shall have verbalized understanding of sleep disturbance and identified interventions to promote sleep of the child
Long term: After 3 days of NI the parent shall have reported improvement in sleep pattern of the child.