ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION Subjective: Nahihirapan ng huminga ang anak ko dahil sa sipon at plema nya as verbalized by the mother
Ineffective airway clearance related to excessive accumulation of secretions secondary to Pneumonia
After 8 hours of nursing intervention the patient will be able to have patent airway as manifested by:
- RR within normal range - Decrease crackles heard upon auscultation - Decrease presence of nasal discharge
>Establish rapport
> Monitor vital signs especially the respiratory rate
> Monitor for feeding intolerance, abdominal distention and emotional stressor
>Advise frequent change in position
>Encourage to increase oral/milk intake
>To develop trust and cooperation of the client
> To obtain baseline data
> These factors may compromise airway
>To mobilize secretion
> To liquefy secretion
GOAL MET After 8 hours of effective nursing intervention the patient is able to have patent airway as manifested by:
- RR = 32 cpm - crackles upon auscultation - presence of mucoid nasal discharge
Nursing Priority No. 1: Ineffective airway clearance related to excessive accumulation of secretions secondary to Pneumonia
>Perform nebulization as ordered
>Perform back tapping or Chest Physiotherapy after each nebulization
> Administer Salinase nasal drops 1-2 gtts/nostril q4-6 >To moisten secretions and alleviate congestion
> To mechanically dislodge secretions from the bronchial walls
Nursing Priority No. 2: Impaired gas exchange related to collection of secretions affecting oxygen exchange across alveolar membrane ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
S/O:
Objective: > RR= 40 cpm > crackles heard upon auscultation > irregular and shallow breathing > (+) nasal flaring > presence of mucoid nasal discharge and productive
Impaired gas exchange related to collection of secretions affecting oxygen exchange across alveolar membrane
After 8 hour of nursing intervention the client will demonstrate improved ventilation and adequate oxygenation as manifested by:
- RR within normal range - ( - ) nasal flaring - Decreased crackles heard upon
>Establish rapport
> Monitor vital signs especially the respiratory rate depth and ease.
> Observe skin color and capillary refill.
>To develop trust and cooperation of the client
> To obtain baseline data
>Determine circulatory adequacy, which is necessary for gas exchange to tissues.
>Rest prevents GOAL MET After 8 hour of nursing intervention the client will demonstrate improved ventilation and adequate oxygenation as manifested by:
>Perform back tapping or Chest Physiotherapy after each nebulization
> Administer Salinase nasal drops 1-2 gtts/nostril q4-6
tissue oxygen demand and enhances tissue oxygen perfusion. >Facilitates liquefaction and removal of secretions.
> To mechanically dislodge secretions from the bronchial walls
Nursing Priority No. 3: Altered Body Temperature related to bacterial invasion in the lungs as manifested by body temperature higher than normal ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Medyo mainit siya pag hinahawakan ko as verbalized by the mother
Objective: >Febrile: 38.2C >skin is warm to touch
Altered body temperature related to bacterial invasion in the lungs as manifested by body temperature higher than normal
After 8 hours of nursing intervention the patients body Temperature will be stabled from 37.9C to 37.5C
>Establish rapport
> Monitor vital signs especially Temperature
>Perform a tepid sponge bath
>Encourage to wear loose clothes
>Encourage patient to take rest.
> Administer Paracetamol drops ( Tempra) 1ml for T 37.8 c
>To develop trust and cooperation of the client > To obtain baseline data
> Sponge bath with warm water evaporates off his skin, thus cooling off the patient.
GOAL MET
After 8 hours of effective nursing intervention the Patients Body Temperature becomes stabled to 37.2C