CUES S= O= >Nasal flaring noted >noisy breathing >productive cougn >presence of rales

NURSING DIAGNOSIS Risk for aspiration R/T increase production of secretions

SCIENTIFIC EXPLANATION Increase production of secretion is a defense mechanism of the body to expel invading pathogens in the lungs. Overproduction of secretions depress gag reflex, which poses the pt for aspiration

PLANNING >After 4 hours of NI, the patients SO will identify causative/risk factors.

NURSING INTERVENTIONS >monitor vital signs. >assess amount and consistency of respiratory secretions and strength of gag/cough reflex.

RATIONALE >for baseline data >to determine pts susceptibility for aspiration

EVALUATION Goal met. After 4 hours of NI, the patients SO identified causative/risk factors.

>auscultate lung sounds frequently

>to determine presence of secretions in the lungs manifested by rales >to prevent aspiration of milk in the lungs

>the pt should be positioned lying on right side after feeding >feed the pt with head elevated >instruct SO importance of compliance to the medical regimen

>to prevent aspiration

> for pt to adhere in the medical regimen

>Administer meds as ordered >to treat underlying condition

CUES S: Nahihirapan Huminga ang baby ko dahil sa ubo as verbalized by the mother. >O: difficulty on breathing Tachycardia V/S taken as follow: T: 36.7 C PR:140bpm RR:64bpm

DIADNOSIS >Impaired gas exchange

SCIENTIFIC EXPLANATION >Pneumonia is an excess of fluid in the lungs resulting from an inflammatory process. The inflammation is triggered by many infectious organisms and by inhalation of irritating agents. Infectious pneumoniasare categorized as community acquired (CAP) or hospital acquired (nosocomial) depending on where the patient was exposed to infectious agent.

PLANNING >After 4 hours of nursing interventions, the patient will relieve from difficulty on breathing.

INTERVENTION >Assess respiratory rate, depth and ease. >Monitor body temperature. >Elevate head of the bed and exchange position frequently.

RATIONALE >Manifestation of respiratory distress is dependent on indicative of the degree of lung involvement and underlying general status.

EVALUATION The patient respiratory rate normalizes and relieved from difficulty on breathing.

>Limit visitors as indicated.

>Institute isolation precaution.

>High fever greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation. >Promotes expectoration,cle aring of infection.

>Administer oxygen as prescribed.

>Reduces likelihood of exposure to other infectious pathogens. >Isolation technique may be desired to prevent spread and protect patient from other infectious process. >Oxygen can relieve the patient from dob.

CUES S= O= >Dyspnea >presence of rales > laboured noisy breathing

NURSING DIAGNOSIS Ineffective breathing pattern R/T respiratory muscle fatigue

SCIENTIFIC EXPLANATION Most acute pulmonary diseases like bronchopneumonia is preceded by a change in breathing pattern. Respiratory failure can be seen with a change in respiratory rate, change in normal

OBJECTIVES >After 3 hours of nursing interventions, the patient will have improve breathing patterns AEB decreased RR.

NURSING INTERVENTIONS >monitor and record vital signs >elevate HOB as appropriate

RATIONALE >To obtain baseline data. >to promote physiological ease of maximal inspiration

EVALUATION Goal met. After 3 hours of nursing interventions, the patient have improved breathing patterns AEB decreased RR-40 cpm

>Nasal flaring noted >productive cough RR: 64 bpm

abdominal and thoracic patterns for inspiration and expiration, change in depth of ventilation (Vt). Breathing pattern changes may occur in a multitude of cases from respiratory muscle fatigue. Other responses would be cyanosis, irritability, restlessness, dyspnea, nasal flaring, and use of accessory muscle.

>administer oxygen as ordered

>to compensate to oxygen insufficiency >to provide pharmacologic relief

>give bronchodilators as ordered

Focus, Data, Action, Response F- Cough D- Lying on bed; conscious and coherent with an ongoing IVF of #6 D5IMB 500cc, regulated at 30 uggts per min. Temperature:36.5, Pulse rate: 120CPM, Respiratory Rate: 52, with DOB, with dyspnea. A- Rendered AM care, Regulated IVF, HOB elevated, kept back dry, encourage to increase oral fluid intake with SAP, encourage SO to increase patients intake of vitamin C, doctors order carried out, continue medications. R- The patient maintain airway patency, but still with cough.