Nursing Care Plan Name: Joshua S. Pascasio Section: BSN 301 Date: July 7, 2013 Patient: Jamila G.

Datuimam

Assessment Subjective Cues: >The Clients mother verbalize minsan pansin mo talaga na nag hahabol siya ng hininga Objective cues: >Coughing >Shallow breathing >Irritable >RR 42

Nursing Diagnosis Impaired gas exchange related to build up of secretions as manifested by DOB and coughing

Planning Goal: After the nursing intervention the client will demonstrate a relief in breathing and maintain airway Objective: The parent will be able to verbalize the cause the therapeutic managements.
Participate in actions to maximize oxygenation.

Intervention Assess respiratory rate, depth, and ease. Observe color of skin, mucous membranes, and nailbeds, noting presence of peripheral cyanosis (nailbeds) or central cyanosis (circumoral). Assess mental status. Monitor heart rate/rhythm. Monitor body temperature, as indicated. Assist with comfort measures to reduce fever and chills, e.g., addition/removal of bedcovers, comfortable room temperature, tepid or cool water sponge bath. Maintain bed rest. Encourage use of relaxation techniques and diversional

Rationale Manifestations of respiratory distress are dependent on/and indicative of the degree of lung involvement and underlying general health status. Cyanosis of nailbeds may represent vasoconstriction or the bodys response to fever/chills; however, cyanosis of earlobes, mucous membranes, and skin around the mouth (warm membranes) is indicative of systemic hypoxemia. Restlessness, irritation, confusion, and somnolence may reflect hypoxemia/ decreased cerebral oxygenation. Tachycardia is usually present as a result of fever/dehydration but may represent a

Evaluation After the nursing intervention the client demonstrates a relief in breathing and maintain airway Goal met The parent is able to verbalize the cause the therapeutic managements. Goal met
The client participates in actions to maximize oxygenation. Goal met

Nursing Care Plan Name: Joshua S. Pascasio Section: BSN 301 activities. Elevate head and encourage frequent position changes, deep breathing, and effective coughing. Assess level of anxiety. Encourage verbalization of concerns/feelings. Answer questions honestly. Visit frequently, arrange for SO/visitors to stay with patient as indicated. Observe for deterioration in condition, noting hypotension, copious amounts of pink/bloody sputum, pallor, cyanosis, and change in level of consciousness, severe dyspnea, and restlessness. Monitor ABGs, pulse oximetry. response to hypoxemia. High fever (common in bacterial pneumonia and influenza) greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation. Prevents over exhaustion and reduces oxygen consumption/demands to facilitate resolution of infection. These measures promote maximal inspiration; enhance expectoration of secretions to improve ventilation. Anxiety is a manifestation of psychological concerns and physiological responses to hypoxia. Providing reassurance and enhancing sense of security can reduce Date: July 7, 2013 Patient: Jamila G. Datuimam

Nursing Care Plan Name: Joshua S. Pascasio Section: BSN 301 Administer oxygen therapy by appropriate means, e.g., nasal prongs, mask, Venturi mask. Administer medication as prescribe by the physician. Date: July 7, 2013 Patient: Jamila G. Datuimam the psychological component, thereby decreasing oxygen demand and adverse physiological responses. Shock and pulmonary edema are the most common causes of death in pneumonia and require immediate medical intervention. Follows progress of disease process and facilitates alterations in pulmonary therapy. The purpose of oxygen therapy is to maintain Pao2 above 60 mm Hg. Oxygen is administered by the method that provides appropriate delivery within the patients tolerance. Medications like bronchodilators will help the client to breath normally

Nursing Care Plan Name: Joshua S. Pascasio Section: BSN 301 Date: July 7, 2013 Patient: Jamila G. Datuimam