Cues Nursing Background Objectives Nursing Intervention Rationale Evaluation

Diagnosis Knowledge
Objective: Independent:
Use of Ineffective airway Presence of After 8 hour Adequately hydrate the Adequate hydration eases The patient is able
accessory clearance related pseudomembrane of nursing patient with IVF or oral expectoration of secretion to excrete
muscles to presence of obstructs airway intervention, fluids as tolerated. by producing less tenacious secretions after an
pseudomembrane thus preventing client would mucus. 8 hour nursing
and tenacious maximal be able to Dependent: intervention
mucus. expulsion of successfully
mucus; tenacious expectorate Nebulize client every 8 It loosens mucus thus
mucus is not secretion. hours or as ordered. facilitating their elimination.
moved freely by Anti infectives eradicate the
the cilia. Administer CPT microragnisms that causes
infection thus reservinf the
Give medicines such as inflammatory response
Amikacin, Dexamethasone, resulting in less mucus
and Pen G Na as production.
prescribed.
Objective: Risk for Vomiting results After 8 hours Independent: The patient
Throat pain Imbalance from activation of of nursing maintained his/her
when eating Nutrition: Less the vomiting intervention Give client soft foods like Soft foods are more readily weight
than the body reflex primarily client’s gelatin and soft fruits to swallowed than firm foods.
requirement by the irritation of weight eat.
related to pain the stomach and would be
and nausea and intestine. Action maintained Feed client small meals at Small frequent feedings are
vomiting potentials travel within frequent intervals better tolerated than larger
through visceral normal meals at longer intervals as
sensory neurons limits for age they are less tiring to the
with vomiting client. Client client.
center in the would be
medulla able to Give client creamed soups, Provides balanced nutrition
oblongata tolerate soft eggs and other to the client without causing
eating larger nutritious foods. pain on swallowing.
amount of
food with Avoid procedures that may Vomiting causes expulsion
less episodes cause nausea and vomiting. of ingested food.
of vomiting.
Dependent: Absence or decrease in pain
Administer pain promotes in better intake of
medication. food.

Objective: Hyperthermia Pyrogenes affect After 8 hours Independent: The patient’s vital
Axillary related to the body of nursing signs returned to
temperature presence of toxin temperature intervention Administer TSB when TSB promotes lowering of normal ranges
of 38C in blood and regulating clients fever is present. temperature through after an hour of
PR:112 bpm tissues mechanism in the temperature evaporation. nursing
RR:35 bpm hypothalamus if would be Apply cold compress to Lowers temp. through intervention
Flushing of the brain, heat lowered, RR armpits, groin areas conduction.
the face perception and and PR are
conservation within the Administering fluids as Dehydration raises the body
increase the body normal tolerated. temperature.
temperature. range.
Provide light blanket and Light blanket warm the
avoid use of heavy patient without trapping the
blankets. heat in the body which
would elevate body temp.
Dependent:

Administer Paracetamol as Paracetamol lowers body

ordered temp. by acting on the
hypothalamic
thermoregulatory center.