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Holy Angel University

School of Nursing and Allied Medical Sciences

NCM 109: Care of Mother and Child (at risk)


Second Semester, SY 2019-2020

Assessment Nursing Scientific Planning Interventions Evaluation


Diagnosis
Explanation

O: Ineffective Pneumonia is essentially After 1 hour of nursing - Monitor vital signs (Provides baseline and to After 1 hour of nursing
airway when fluid or pus gets intervention, the S/O will track any changes) intervention, the
 Rapid clearance trapped in the alveoli of be able to verbalize client’s S/O verbalized
breathing related to the the lungs and impaired gas understanding on different understanding on
● (+) productive increased exchange results. This can airway clearance - Monitor respirations and breath sounds, noting rate different airway
cough with production of impact one or both lungs. techniques that may help and sounds such as tachypnea, stridor, crackles, or clearance techniques
yellow sputum respiratory Pneumonia can be caused the client to improve wheezes (To indicate if there’s any respiratory that may help the
production secretions by a virus, bacteria, respiratory function. distress and/or accumulation of secretions) client to improve
fungus, or from inhaling respiratory function.
● Dyspnea something (a chemical,
● Diminished inhalant, or aspirating on After 8 hours of nursing - Position head appropriate for age and condition
and food or fluid). This can be intervention, secretions (To open or maintain open airway in an at-rest or After 8 hours of
adventitious of particular risk to those will be mobilized, airway compromised individual) nursing intervention,
sounds with a weakened immune patency will be goal partially met.
(crackles) system or unable to keep maintained free of
your own airway clear (for secretions, as evidenced  The patient
- Suction nose, mouth, and trachea prn (To clear was able to
example, unable to cough by patient’s ability to airway when excessive or viscous secretions are
or maintain consciousness effectively cough out demonstrate
VS: blocking airway) deep-breathing
due to neurological or secretions, clear lung
T- 36.7℃ other injury). sounds, and and coughing
uncompromised exercise every
PR- 128 bpm - Encourage the client deep-breathing and coughing 1-2 hours
respiratory rate.
exercises (To maximize effort) during the day.
RR- 45 cpm
 Client’s
respiratory rate
- Perform or assist the client in learning airway is within
clearance techniques, such as postural drainage and normal range (
percussions (Various therapies/modalities may be RR – 30 cpm)
required to acquire and maintain adequate  Inspiratory
airways and improve respiratory function and crackles can
gas exchange) still be heard

- Administer medications such as expectorants, anti-


inflammatory agents, bronchodilators, and mucolytic
agents as indicated (To relax smooth respiratory
musculature, reduce airway edema, and mobilize
secretions)

Nursing Care Plan: Pediatric Pneumonia