Nursing Care Plan

ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

S> The patient's Ineffective airway Pneumonia After 15 minutes Independent: After 15 minutes of
father verbalized, clearance related happens when of nursing nursing intervention,
“ Halatang to retained normal lung intervention, the 1. Assess and 1. To note for any the patient manifested
nahihirapan siyang secretions clearance are patient will monitor VS q4. deviations from a patent airway
huminga kasi may secondary to overwhelmed by improve airway normal ranges. clearance as evidenced
plema na hindi pneumonia an inoculum of patency as by (-) pallor,
niya mailabas. bacteria and a evidenced by (-) 2. Auscultate lung 2. To identify and (-)crackles on both
Saka kapag classic pallor, (-)crackles fields for breath note abnormal lung fields during
humihinga siya inflammatory on both lung fields sounds. breath sounds. expiration, and
may naririnig ako response occurs. during expiration, collection of thick,
na parang may An exudates of and collection of 3.Monitor infant 3. May tenacious mucus.
nakabara.” fibrin-containing thick, tenacious for feeding compromise
fluid, bacteria, mucus. intolerance, airway.
O>Patient has polymorphonuclea abdominal
pallor; non- r leukocytes and distention and
productive cough; erythrocytes fills emotional stressors
nasal flaring and the alveoli.
use of accessory Because of this, it 4. Keep 4. To avoid
muscles noted damages the environment irritation.
when breathing. c endothelial lining allergen-free.
crackles on both of the lungs which
lung fields during causes the
expiration. excessive 5. Elevate the head 5. To promote
accumulation of of the bed of the chest expansion.
T=38.0 C mucus. Ciliary patient or as
P= 132 bpm action is also tolerated.
R=62 bpm ineffective. Thus, 6. To enhance
mucus plugs were 6. Reposition the ventilation.
Lab Results: formed. If some patient every 2
Results of ABG: airways are hours.
obstructed 7. Determine the
PO2 = 46mmHg completely, lung 7. Note the characteristics of
 Nursing Care Plan

HCO3= 21.5 m compliance will characteristics of sputum

eq/l fail, portions of secretions
O2 Sat= 80% the lungs will be suctioned.
underventilated Suction nasal/oral
and inadequate as needed.
arterial
oxygenation may Dependent:
result. 1. Medications
1. Administration ordered helps
of medications as loosen the
ordered by MD. secretions in the
airway.

2. Helps increase
2. O2 O2 supply in the
Reference: administration as body. It lessens
Medical-Surgical ordered by MD. the effort of the
Nursing, Maxine body to
L. Patrick compensate for
O2 defiency.

3. Promotes
3. Provision of vasodilation in
supplemental the airway that
humidification leads to increase
such as O2 supply in
nebulization and circulation.
steam inhalation as
ordered by MD.
4. To clear airway
4. Suction when secretions
nasal/oral as block it.
Nursing Care Plan

needed.
Collaborative:

1. Refer to
laboratory for
sputum collection,
chest x-ray and
ABGs.

Health Teaching:
To help liquefy
Encourage the secretions.
mother/ relatives to
increase patient's
fluid intake to at
least 1500 ml/day.
Promotes
Encourage the vasodilation of
mother/relatives to airway.
provide warm
liquids rather than
cold as appropriate.
To prevent
Instruct the mother aspiration into
to avoid the use of lungs.
oil-based products
around the nose.
Prevents or
Instruct the lessens fatigue.
mother/caregivers
to provide time to
rest.
Nursing Care Plan

Gravity and other

Instruct the mechanical
mother/caregivers factors may help
how to provide to disludge
chest secretions.
physiotherapy.
 Nursing Care Plan

ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

S> The mother Impaired gas Pneumonia is the After 15 minutes Independent: After 15 minutes
verbalized, exchange related inflammation of of nursing of nursing
“Tinimbang siya to collection of the lung intervention, the Assess and monitor To note any intervention,
kanina, bigla na secretions parenchyma patient will VS q4. deviations from patient manifested
lang nag-iba yung affecting oxygen caused by various manifest normal ranges. adequate
kulay niya. exchange across microorganisms. adequate oxygenation of
Putlang-putla siya. alveolar Usually normal oxygenation of Provide a well- To keep the tissues as
Nahihirapan pa rin membrane defensive tissues as ventilated patient evidenced by (-)
siyang huminga. secondary to mechanisms of the evidenced by (-) environment. comfortable. pallor, (-) nasal
Para siyang pneumonia respiratory system pallor, (-) nasal flaring, (-) use f
kinakapos ng are impaired. flaring, (-) use f Keep environment To avoid irritation. accessory muscles
hangin. Excessive accessory allergen-free. during breathing
productions of the muscles during and RR=40bpm.
O> Patient has goblet cells, breathing and Auscultate lung To identify and
pallor;productive accumulation of decrease of RR fields for breath note abnormal
cough; with mucus, infectious from 62 bpm to sounds. breath sounds.
crackles on both debris and 40 bpm.
lung fields during remnants of the Place patient in Facilitates gas
expiration, use of inflammatory position that best exchange.
accessory muscles process leaks out facilitates chest
(sternocleidomasto of the vessels and expansion.
id and intercostal damages the
msucles) noted. alveolocapillary Reposition the Enhances
membrane. This patient every 2 ventilation.
Results of ABG: decreases the hours.
surface area for
PO2 = 46mmHg gas exchange. In Reduce fever to High fever
HCO3= 21.5 m pneumonia, some normal level by increases oxygen
eq/l alveoli are tepid sponging. demands of tissues
O2 Sat= 80% underventilated
while others are Assist patient to Activity reduces
T= 38.0 C collapsed or fluid gradually increase cardiovascular
 Nursing Care Plan

P=132 bpm filled. ambulation. deconditioning

R=62 bpm Oxygenation and and promotes
carbon dioxide return of strength.
elimination are
compromised. Provide adequate It decreases
rest periods to oxygen demands
patient. of the tissues

Dependent:

1. Administration of 1. Medications
medications ordered helps rid
(antibiotics) as of
ordered by MD. microorganisms. It
speeds resolution
of bacterial
pneumonia
leading to
improved gas
exchange.

2. O2 2. Helps increase
administration as O2 supply in the
ordered by MD. body. It lessens the
effort of the body
to compensate for
O2 defiency.

3. Provision of 3. Promotes
supplemental vasodilation in the
humidification such airway that leads
as nebulization and to increase O2
Nursing Care Plan

steam inhalation as supply in

ordered by MD. circulation.

Collaborative:

1. Refer to 1. To note if there

laboratory for are any deviations
sputum collection, from normal.
chest x-ray and
ABGs.

Health Teaching:

Encourage the To help liquefy

mother/ relatives to secretions.
increase patient's
fluid intake.

Encourage the Promotes

mother/relatives to vasodilation of
provide warm airway.
liquids rather than
cold as appropriate.

Instruct the mother To prevent

to avoid the use of aspiration into
oil-based products lungs.
around the nose.

Instruct the Prevents or lessens

mother/caregivers fatigue.
Nursing Care Plan

to provide time to
rest.

Instruct the Gravity and other

mother/caregivers mechanical factors
how to provide may help to
chest physiotherapy. disludge
secretions.
Nursing Care Plan
 Nursing Care Plan

ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

S> Px’s mother Alteration in Pneumonia is an After 1 hr of Independent: After 1 hr of
verbalized: “Ang thermoregulation: inflammation of nursing nursing
init ng katawan Hyperthermia r/t the lung intervention, the 1. Monitor body 1. To evaluate intervention, the
niya ngayon. the inflammatory parenchyma patient will have a temperature q1-q4 effectiveness of patient had a
Parang mapapaso process of the caused by various decrease of or more often. interventions. decrease of
ka pag hinawakan lungs secondary to microorganisms. temperature from temperature from
mo siya.” pneumonia This inflammation 38º to 37.5 º. 2. Employ 38º to 37.5 º.
has many effects. measures to reduce
Locally, erythema, excessive fever,
O> Px’s skin is warmth, edema, such as removing
flushed and warm pain and impaired excess blankets.
to touch; functioning can be
decreased seen. The systemic 3. Apply ice bags 2-5. These
sensorium; dry effects are fever, to patient’s axilla measures promote
lips and oral leukocytosis, or groin. patient comfort
mucosa; lethargic malaise, anorexia and lowers body
and sepsis. The 4. Give tepid temperature by
V/S inflammatory sponge bath. heat loss.
T=38 º response is often
P=132 bpm confined to the 5. Use hypothermia
R=62 bpm site, causing only blanket if temp
local signs and rises to 39.4 º.
symptoms.
However, 6. Monitor rate and 6. Increased HR,
systemic rhythm, BP, RR, decreased BP
responses can LOC and level of may indicate
occur. Fever is the responsiveness and hypovolemia,
most common sign capillary refill time which leads to
of a systemic q1-q4. decreased tissue
response to injury perfusion. Cool
or infection and it and blanched or
is most commonly mottled skin may
 Nursing Care Plan

caused by also indicate

endogenous decreased tissue
pyrogens (internal perfusion.
substances that Increased RR
cause fever) compensates for
released from tissue hypoxia.
neutrophils and
macrophages 7. Increase 7. Insensible fluid
(specialized forms patient’s oral fluid loss increases by
of leukocytes). intake as tolerated. 10% for every
These substances 1ºC increase in
reset the temperature. It
hypothalamic prevents
thermostat, which dehydration.
controls body
temperature and Dependent
produce fever. 1. Administer 1. Antipyretics act
antipyretic on hypothalamus
Brunner and medication, as to regulate
Suddart’s prescribed. temperature.
Textbook of
Medical-Surgical
Nursing 11th Ed Collaborative
1. Refer to To modify
physician if fever interventions.
persists despite of
the interventions
given.

2. Refer to
laboratory for To note if there is
white blood cell an existing
count and for infection
Nursing Care Plan

culture and
sensitivity tests.

Health Teaching
1. Instruct the 1. Prevents
mother the dehydration due
importance of to insensible fluid
maintaining her loss.
son well-hydrated
during febrile
episodes. Patient
should drink plenty
of water and milk
as tolerated.

2. Teach the 2. Determines if

mother how to interventions are
monitor her son’s effective.
temperature.

3. Teach the 3. Prevents

mother how to complication of
recognize signs of hypovolemia.
hypovolemia such
as HR, BP, RR,
level of
responsiveness.

4. Discuss 4. Prevent
precipitating occurrence of
factors of fever fever and other
with the mother health-related
illnesses.
Nursing Care Plan

5. Encourage 5. Reduces fever.

adherence to other
aspects of heath
care management,
including dietary
habits.