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NURSING CARE

PLAN
Client: AM 1 yr 9 months old Male Admitting Diagnosis: PCAP
Assessment/C Diagnosis Goals and Interventions Rationale Evaluation
ues Objectives
Subjective: Ineffective Goal: After 3 days,
‘kapag umuubo Airway the client will be
siya maririnig Clearance able to have
mo na marami related to maintained airway The client was
siyang plema” secretions in patency and normal able to maintain
the bronchi as breathing pattern. patent airway
manifested by patency and
Objective: dyspnea, * Position the To open or normal
-Use of adventitious Objectives: head of the maintain airway breathing
accessory sounds during 1. After 8 hours of client when at rest pattern
muscles auscultation, the shift, the client appropriately
- nasal flaring and increase will be able to have for her age
-respiratory rate respiratory rate. a decrease and condition 1. Effectiveness:
of 74 breaths respiratory rate The client was
per minute within normal range To enhance able to:
-crackles and will decrease * Elevate head drainage or a decrease
auscultated at difficulty of of bed and/or ventilation of respiratory rate
right middle breathing. change diff. lung within normal
lung position every segments and range and will
- producitve 2 hours to promote lung decrease difficulty
of breathing
cough noted expansion
b. reduce
-wheezes
infection, improve
To assess the the cough, inhibit
*Monitor effectiveness of inflammatory
respiration the medications processes and
rate and and promote
breath sounds. interventions as bronchodilation.
well. c. manage client’s
condition and to
* Review To identify the assess
client’s causative effectiveness of
therapeutic
laboratory factors, to regimen.
results and verify
screening. appropriatenes 3.The nursing
s of illness and intervention was
know what the adequate to the
focus of client.
interventions.
4. The nursing
* Monitor To know the intervention was
child’s feeding factors that appropriate to
intolerance, may the client.
abdominal compromise
distention and airway of the 5. The nursing
emotional child. intervention was
stressor accurate to the
client.

* Continue
administering To reduce
prescribed infection,
medications improve the
and follow cough, inhibit
doctor’s order inflammatory
processes and
promote
*Demonstrate bronchodilation
proper back .
tapping to the
client’s mother To promote
or relative. mobilization
and
dislodgement
* Make the of secretions in
environment lower RTI.
free from dust,
smoke,
feathers, etc. Inform and help
in the
* Provide maintenance
opportunities cleaning of the
for child to get room to avoid
rest. (3.g. these agents
quiet and
peaceful To relieve
environment) restlessness
due to difficulty
of breathing
and to provide
a sickness-
alleviating
Encourage environment.
mother and
relative to
responsibly
promote Hydration can
increase fluid help liquefy
intake to the viscous
child and ask secretions and
mother to improve
assist in secretion
monitoring of clearance.
the client’s
intake and
output.

Collaborative
Nebulization
Chest
Physiotherapy
Health
Teaching:
• -Benefits of
proper
positioning of
the child
• -Relative
causative
factors of her
child’s
condition
• -Importance
of continued
medication
and
monitoring of
her child’s
condition.