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NURSING CARE PLAN CUES NURSING DIAGNOSIS P>Ineffective Airway Clearance SCIENTIFIC BACKGROUND Bacterial microorganism enter the airways OBJECTIVE NURSING INTERVENTIONS RATIONALIZATION EVALUATION Date: April 24, 2012 Time: 6:30 AM

SUBJECTIVE: > May halak siya at nahihirapan ding huminga, as verbalized by the watcher. OBJECTIVES: >With O2 support via face mask at 5LPM >Weak in appearance >irritable >presence of dyspnea as evidenced by RR 83 cpm >(+) crackles heard upon auscultation on both lungs >(+) DOB noted >cried at times >v/s taken as follows: Temp: 37.8 C, RR: 83cpm, PR: 130bpm, O2 sat: 85

Date: April 24, 2012 Time: 6:00AM Within 30 min of rendering nursing interventions, the patient will maintain airway patency, expectorate/ clear secretions readily and demonstrate absence/ reduction of congestion with breath sounds clear, respirations noiseless, improved O2 exchange (absence of cyanosis, O2 sat results within client norms) Objectives: >With no O2 support >fair looking

E>related to inability to maintain clear airway as characterized by presesnce of dyspnea, (+) crackles, (+) DOB noted.

Inflammation of the lungs

Air sac filled with pus & other liquids

Presence of obstructions in the airways

Inability to breathe properly

INDEPENDENT: Monitor v/s of the To assess changes, have patient especially RR a baseline data and note and pulse complication Goal: Goal partially met Auscultate breath To ascertain status and sounds and assess air note progress Evidences: movement >still with O2 support via Face Observe sx of To assess for any mask at 5LPM respiratory changes and note >fair-looking distress(inc. RR, complication >not irritated restlessness, use of >absence of dyspnea accessory muscles in as evidenced by RR breathing, capilliary of 60cpm refill) > decrease crackles heard upon Elevate the head of To take advantage of auscultation on both the bed into semi gravity and dec. lungs fowlers and change pressure on the >(-) DOB noted position every 2 hrs. diaphragm enhancing >O2 sat of 93% drainage to different >v/s taken as lung segments. follows: Temp 36.8 C,RR: Increase fluid intake 60cpm, PR: 125bpm within level of To help liquefy tolerance. secretions

Brunner & Suddharts Textbook of Medical-Surgical Nursing 12th Edition

>absence of dyspnea, RR will be within Normal range >(-) crackles auscultated on both lungs >(-) DOB noted

CPT every after nebulization Maintain a wellventilated and quiet envt. DEPENDENT: Administer analgesicsparacetamol 1251 supp sup Q4 Administer salbutamol neb +2ml PNSS Q6

To hep loosen secretions and help expectorate secretions. Promote enough rest and promote wellness.

To improve cough when pain is inhibiting effort.

To provide pharmacologic effect as a bronchodilator to help loosen secretions.

CUES

NURSING DIAGNOSIS P> Hyperthermia E> related to bacterial invasion in the lungs as manifested by body temperature higher than normal, skin

SUBJECTIVE > Nilalagnnat po sya mula kagabi, as verbalized by the watcher OBJECTIVES: >febrile @ 37.8 C

SCIENTIFIC BACKGROUND Bacterial microorganisms (e.g. pulmonary pathogens) enter the airway

OBJECTIVE

NURSING INTERVENTIONS INDEPENDENT: > Monitor Pts temperature q1 hr

RATIONALIZATION

EVALUATION Date: April 24,2012 Time: 6:30 AM

Date: April 24, 2012 Time: 6:00AM After 30 min of rendering nursing intervention, patients body

> To determine if the Pts temperature is above the normal body temperature > To maintain hydration status and

Goal met Evidences: >Normal temp of 36.8 C

>Increase fluid intake in level of

warm to touch. >Skin warm to touch >Weak in appearance >cried at times >v/s taken as follows: Temp: 37.8 C, RR: 83cpm, PR: 130bpm, O2 sat: 85 % These bacteria/viruses infects the lung/s

temperature will return to normal range 36-37.5 C from 37.8 C.

tolerance

increased fluid intake helps lessen febrility

Inflammation of the lung/s

Objectives: >Normal temp of 36-37.5C >Skin will cool off > fair looking > never cry

> Encourage the Pts guardian to do tepid sponge bath every fever episodes.

> Sponge bath with warm water evaporates off his skin, thus, cooling off the Pt

>Skin cool off > fair looking > never cry >v/s taken as follows: Temp 36.8 C,RR: 60cpm, PR: 125bpm

DEPENDENT: > Administer antipyretic medications as prescribed paracetamol 1251 supp sup Q4 > Promotes return of body temperature to normal

Signs and symptoms of Pneumonia (e.g.temperature may be greater than 37.5C), dyspnea, (+) crackles, (+) DOB

Brunner & Suddharts Textbook of Medical-Surgical Nursing 12th Edition

CUES

NURSING DIAGNOSIS

P> Impaired Gas SUBJECTIVE: >Nahihirapan syang Exchange huminga tapos nangitim pa sya, as E> r/t impaired verbalized by the oxygen demand and watcher supply as manifested by O2 support, weak in appearance, irritable, use of OBJECTIVE: >With O2 support accessory muscles via face mask at in breathing, 5LPM presence of >Weak in dyspnea, with Mucus production appearance crackles and DOB. Manifested by >irritable crackles >use of accessory muscles in breathing >presence of dyspnea as Bacteria invades evidenced by RR 83 alveolar cell in the cpm lungs >(+) crackles heard upon auscultation on both lungs >(+) DOB noted >capillary refill 1Impaired functioning 2sec of alveoli for gas >cried at times exchange

SCIENTIFIC OBJECTIVE BACKGROUND Pathological Entry (inhalation) of Date: April 24, 2012 organism: Bacteria or Time: 6:00 AM Viruses After an hour of nursing interventions, the patient will be able Occurrence of demonstrate localized improved ventilation inflammation and oxygenation of tissues. Objectives: >With no O2 support via face mask at 5LPM >fair-looking >not irritable >without the use of accessory muscles in breathing >no crackles heard upon auscultation >no DOB noted >never cry

NURSING RATIONALIZATION INTERVENTIONS INDEPENDENT: Monitor v/s of the patient especially RR and pulse.

EVALUATION
Date: April 24,2012 Time: 7:00 AM

To assess changes, have a baseline data and note complication

Goal partially met Evidences:

Auscultate breath To ascertain status and sounds and assess air note progress movement. Note respiratory rate, depth; use of accessory muscles in breathing, capillary refill and cyanosis. Elevate the head of the bed /position the client appropriately. Provide adequate rest, sleep and limit activities to within tolerance. Keep the envt allergen/pollutant free. DEPENDENT: To evaluate degree of compromise

To maintain patent airway.

Helps limit oxygen consumption

>With O2 support via face mask at 5LPM >fair-looking >not irritable >still with the use of accessory muscles in breathing in minimal >with crackles heard upon auscultation >no DOB noted >never cry >v/s taken as follows: Temp 36.8 C,RR: 60cpm, PR: 125bpm

To reduce irritant effect on airways

>v/s taken as follows: Temp: 37.8 C, RR: 83cpm, PR: 130bpm, O2 sat: 85 Impaired Gas Exchange Brunner & Suddharts Textbook of Medical-Surgical Nursing 12th Edition

Administer medication as indicated, paracetamol 1251 supp sup Q4 (antipyretic), salbutamol neb +2ml PNSS Q6 (bronchodilator), ampicillin 185mg IV Q6 (antibiotic)

To treat underlying conditions.

Administer O2 support tolerated by the patient as ordered. Suctioning as indicated.

To facilitate breathing.

To maintain patent airway