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‘Assessment | Diagnosis | inference | Panning | intervention | Rationale Evaluation $>*Nabibrapan ya | ineffective Bacterial | After 2hoursof | > Monier > With seston inte | Ae 12 hours of syang hamings saka | Airway microorganism | Nursing ‘respiratory pateres, | airway; therespirwory | Nursing Intervention, lagina lang sumesuka | Clearance | enter the airways Intervention, the | tuding rte, depth, | rae wll increase the P's breathing had ng lema” as related to 1 Pr’sbreahing | tt. cuneate verbalzedby thePv’s | inailtyto | Iatamnation ot | will tave no ; : sounds pao: bance | flees | more 7 Asst wih | his the | cracks geges 2 , clearing secretions | clignt to cough up airway as : adventtios | fom pharyenty [secrtios Gente PMeert when Asoc filed Blacyen by Me O>(-)sputam ——|ehaacnizad | ANSI | sounds present | ong sus and | steig ofthe | atte production by (+) sputum, Feud | (erackkes\garges) | gestlesuton of the | posterior pharyx may Rapid, shellow | (+)erackles, . when auscalated | orl pharynx if | stimulate coughing nd brated alow | ae neessary help emove secretions (*)oreckles, | breathing | ohsruions inthe es > Ches physical ae oe therapy helps bile Inability 10 >Provide postural | bronchial secretions: y rainage, percussion, breathe properly and vibration as ordered > Bronchodilators decrease airway >Adninser | reisuace sendy 0 nedicaions suchas. | brochocorsticion bronchodilators or ‘inhaled steroids as ere. Assessment | Diagnosis _| Inference Planning _| Intervention Rationale Evaluation S> "May lagsatpo | Altered body Baccral | Aer 2howsof | >MonitorDy’s | >Todetemine ifthe | Ater2 hrf Nursing yang anak ko.” | temperature microorganisms | Nursing temperaturegl br |Ustemperuureis | intervention, the P's is weralized hy the | related to bacterial | (eg pulmonary | Intervention the hove he normal body | temperature had Pr'smother. invasion inthe | pathogens) enter_| P's temperature temperature decreased from 39.8 °C hunge a theairvay | will decrease wrae smanifasted by 1 from 308 C10 > Allows the patient to > febrile body temperature ‘hse | nomalrange | > Encourage Pio [recuperate physical | Alter? bof Nursing moist skin | higher than Insctriaivimses | (366-375 °C) | rest strength Innervestion, the P's tachypaea, RR= | nonnal, tckypmea, | infete dhe lang’ skin has cooled off bit 33pm (Jerackes 4 After 2 hours of > Tomintain (enacles Inflammation ofthe | Nursing hydration stan end Jungs | tnervention the | >Eneourage Pio | ncreased Nid inte 1 Prsskin will | increase Mud intake | helps lessen febriity Sigmund | cool af symptoms of > Sponge hah with Paeumonia ‘war water evaporates (e-gtempecatre of his sk, tus, may be greater than > Encourage the P's | cooing off he Pt 37.0, tchypne, ‘guardian odo tepid snug ith sponge ath > Promoees eum of _reenish steretons body temperature 10 roma > Administer antipyretic medications as eserted Assessment Diagnosis_| Inference | Planning | Intervention Rationale Evaluation 5 Ibalanced Bacteisorvins | Ars hoursof |> Assess forrocent |>The consoquences | AMter4 hours of Nursing kumain, yung gatas | Nutrition dueto | attacks the lings | Nursing changes in of malnutrition ean | Iterventon the Pt sinusuks lang panen | frequen vomiting Iterventon,the | pisiological sous | lead oa furher | started king foods ya," and sand noteating the | weakened immune | wil sta taking | tht may interfere | decline inthe ‘which ke usually eat “Mas payat vangayon, | usualfoods taken | ystems -—_| foods which he | witk muon | patient sconditon | (crackers) ti angakas nanan | as manifested by 1 usually cat (rice, that ker cares kumain” decreased weight, | Preumonia | crackers, chicken sell-perpeuaing i After hours of Nursing ss yealized by the P's | food aversion, and 1 breascete) otsecognized and | lterveion the Pr di't grandmother. weakness. Symptoms of vee, ‘omitanymore the Preumonie; | After 4 hours of ingested mile > vomits ingested causes or — | Nursing > Often toddlers will milk vomiting, may | Intervention, the | > Provide ‘eat moe fod if other Foad aversion experience | Ptwillnat vomit | companionshipat | people are present t Decresed wt profound anymore the | mealtime wo roeatimes, weakness weakness we lass | ingested milk | encourage fora long ine sutitonal intake > Dermine bealhy body ‘weigh forage end bight > Asessclicnts ability obtain and use essential sutiens > Proin-calore ‘malnutrition most fin accompanies & disease process > Cases of vitamin D deficiency have been reperid among dake shinned toddlers who were exelusively roast edand were ros given ‘supplement! tain

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