III.

Nursing Care Plan

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

Objective:
> RR= 38 cpm
> crackles
heard upon
auscultation
> presence of
mucoid nasal
discharge
> productive
cough
> Irritable

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:

- RR = 38 cpm
- ( - ) nasal flaring
- Decreased
crackles heard
upon auscultation



cough

> Irritable
auscultation

> Encourage rest.




>Assist with nebulizer
treatments.



>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