CHAPTER VII

MEDICAL AND NURSING MANAGEMENT

Nursing Care Plan

ASSEESSMENT EXPLANATION OF PLANNING INTERVENTION RATIONALE EVALUATION

THE PROBLEM
SUBJECTIVE: Chronic lung STO: ➢ Assessed ➢ Tachypnea After 8 hours of
“Nahihirapan disease is a ➢ After 8 hours respiratory indicates nursing
huminga si baby general term for of nursing status, noting respiratory intervention,
kaya naka-oxygen long-term intervention, signs of distress the client
at hindi normal respiratory the child will respiratory especially when maintained
yung sounds ng problem in be able to have distress such RR is airway passing,
paghinga niya” premature clear breath as tachypnea, >75breaths/min; clear breath
as verbalized by babies. It Is sounds and nasal flaring, expiratory sounds and
the mother of also known as regular grunting, grunting regular
the child. Bronchopulmonary breathing retractions or represents breathing
Dysplasia (BPD). pattern. crackles. attempt to pattern.
OBJECTIVE: CLD in infant’s maintain
➢ Oxygen in use VEINS that LTO: alveolar
via nasal damaged tissue ➢ After 2 days of expansion;
cannula in the newborn’s nursing nasal flaring
➢ Use of lungs is intervention, is a
accessory breathing and the child will compensatory
muscle noted health problems be able to mechanism to
it occurs when a establish a increase
normal diameter of
➢ Irregular newborn have respiratory nares and
breathing been injured. pattern and increase oxygen
pattern normal skin intake.
➢ O2 saturation color. ➢ Assessed skin ➢ Lack of oxygen
is 90% color for will result in
development of cyanosis.
NURSING cyanosis.
DIAGNOSIS: ➢ Positioned the ➢ To enable the
Ineffective patient in semi body to
airway clearance fowler’s recuperate and
related to position. repair.
chronic lung
disease as ➢ Instructed the ➢ To decrease the
evidenced by mother to let metabolic rate
cyanosis her baby rest, and oxygen
minimize consumption.
stimulation and
energy
expenditure.
➢ Instructed the ➢ Increased mucus
mother to and sputum
increase fluid secretions can
intake. lead to
dehydration;
increased water
intake can help
 dissolve
secretions.
➢ Kept ➢ Presence may
environment trigger
allergen-free allergic
such as dust, response that
feather may cause
pillows, smoke further
or pollen. increase in
mucus
secretion.
 ASSESSMENT EXPLANATION OF PLANNING INTERVENTION RATIONALE EVALUATION
THE PROBLEM
Objective: Lungs that are STO: After 4 ➢ Assessed ➢ Manifestations After 2 days of
➢ Preterm birth lacking in hours of nursing respiratory of respiratory nursing
➢ With oxygen via surfactant (a intervention, rate, depth distress is intervention,
nasal cannula solution that the infant will and ease. dependent on the patient
regulated at 5 prevents the experience an indicative of shows normal and
liters per lungs from effective the degree of effective
minute sticking breathing lung respiratory
➢ RR: 37 together during pattern as involvement pattern
breaths/min breathing), are evidenced by no and underlying
➢ O2 saturation considered episodes of general
of 90% premature. Any apnea. status.
➢ With episodes premature baby ➢ Position head ➢ To promotes
of apnea (5-10 born before 37 appropriate expectoration,
seconds) weeks age of LTO: After 2 for age and clearing or
gestation can be days of nursing condition to infection.
NURSING diagnosed with a intervention, open or
DIAGNOSIS: premature lung. the patient will maintain open
Ineffective Breathing establish a airway to
breathing problems in normal, determine
pattern related premature babies effective ability to
to immature may be due to an respiratory protect own
pulmonary immature lung pattern as airway.
development rather than a evidenced by ➢ Instructed the ➢ To prevent
specific disease absence of mother to drying of
or complication. cyanosis and increase oral secretions.
apnea. fluid intake
of the
patient.
➢ Humidifier at ➢ To loosen
bedside. secretions.
➢ Instructed the ➢ To help
mother to maintain
positioned the adequate lung
patient in expansion thus
semi fowler’s preventing
position. buildup of
secretions.
 ASSESSMENT EXPLANATION OF PLANNING INTERVENTION RATIONALE EVALUATION
THE PROBLEM
Subjective: Respiratory STO: After 8 ➢ Assessed for ➢ Abnormality After nursing
n/a distress results hours of nursing respiration indicates intervention,
from surfactant intervention, noting for respiratory the patient was
Objective: deficiency, the patient will rate, rhythm compromise. able to maintain
➢ With oxygen via usually seen in be able to and pattern. airway patency
nasal cannula premature maintain airway ➢ Assessed airway ➢ Maintaining the and free from
regulated at 5 infants, but can patency and the for patency. airway is respiratory
liters per occur with mother will always the distress.
minute decreased report first priority,
➢ Episodes of frequency in improvement if especially in
apnea term infants. oxygen exchange case of trauma,
➢ V/S taken as Incidence rates acute
follows: range from 86% neurological
RR: 37 at 24 weeks to LTO: After 3 decompensation,
breaths/min less than 1% at days of nursing or cardiac
O2 Saturation of 39 weeks. intervention, arrest.
90% Respiratory mother will
distress should report the ➢ Auscultated ➢ Adventitious
NURSING be anticipated reduction of lungs for breath sounds
DIAGNOSIS: in the setting congestion with presence of may indicate
of any preterm breath sounds adventitious presence of
Risk for delivery, clear and breath sounds. mucous plug,
respiratory delivery where noiseless increasing
distress amniotic fluid respiration. airway
indices indicate resistance or
pulmonary presence of
immaturity and fluid along
in any infant larger airways.
born to a ➢ Assessed ➢ Increasing
diabetic mother. changes in lethargy,
mental status. confusion,
restlessness or
irritability
can be early
signs of
cerebral
hypoxia.

➢ Assessed cough ➢ Consider

for possible causes
effectiveness for ineffective
and cough:
productivity. respiratory
muscle fatigue,
severe
bronchospasm,
thick tenacious
secretions and
others.