This nursing care plan addresses a child patient experiencing difficulty breathing due to sinus and phlegm from pneumonia. The plan outlines 3 nursing diagnoses: 1) Ineffective airway clearance related to excessive secretions from pneumonia, 2) Impaired gas exchange due to secretions affecting oxygen exchange in the lungs, and 3) Altered body temperature related to the bacterial infection manifesting as a fever. Interventions include monitoring vitals, assisting with nebulizer treatments, chest physiotherapy to remove secretions, saline drops, rest, and fever medication. The goals are to improve breathing, oxygen levels, and stabilize the fever within 8 hours.
This nursing care plan addresses a child patient experiencing difficulty breathing due to sinus and phlegm from pneumonia. The plan outlines 3 nursing diagnoses: 1) Ineffective airway clearance related to excessive secretions from pneumonia, 2) Impaired gas exchange due to secretions affecting oxygen exchange in the lungs, and 3) Altered body temperature related to the bacterial infection manifesting as a fever. Interventions include monitoring vitals, assisting with nebulizer treatments, chest physiotherapy to remove secretions, saline drops, rest, and fever medication. The goals are to improve breathing, oxygen levels, and stabilize the fever within 8 hours.
This nursing care plan addresses a child patient experiencing difficulty breathing due to sinus and phlegm from pneumonia. The plan outlines 3 nursing diagnoses: 1) Ineffective airway clearance related to excessive secretions from pneumonia, 2) Impaired gas exchange due to secretions affecting oxygen exchange in the lungs, and 3) Altered body temperature related to the bacterial infection manifesting as a fever. Interventions include monitoring vitals, assisting with nebulizer treatments, chest physiotherapy to remove secretions, saline drops, rest, and fever medication. The goals are to improve breathing, oxygen levels, and stabilize the fever within 8 hours.
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
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:
>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