Jerimae De Dios Carl

Elexer C.Ano
3 y/o July 8 2008
SCIENTIFIC EXPECTED
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE
EXPLANATION OUTCOME
S>Ø Ineffective Airway Normally the lungs are Short term: >Establish rapport >To gain the client and The client shall have
O> The pt manifested clearance r/t retained free from secretions. But SO’s trust. maintained airway
the ff. secretions 2° BPN with Bronchopneumonia, After 2-4° of NI, the >Monitor VS. >To obtain data for patency AEB clear
bacteria are invading the client will be able >Place on an orthopneic comparison. breath sounds.
 DOB lung parenchyma thus, maintain airway position >To maintain patent
 Orthopnea producing inflammatory patency AEB clear >Elevate HOB airway
 Wheezes on both process. And this breath sounds. >To take advantage of The client shall have
lung fields response leads to filling >Encourage deep gravity ↓pressure on expectorated
 Chest indwelling of the alveolar sacs with Long term: breating exercise and the diaphragm. retained secretions
exudates leading to coughing exercise >To mobilize secretion. and maintained
 Uses intercostal
consolidation. Due to After 1- 3 days of NI the >Encourage to ↑ fluid normal breathing
muscles upon
consolidation the airway client will be able to intake >To moisten secretions pattern.
respiration.
is narrowed thus wheezes expectorate retained for easy expectoration
 Nasal flaring
is being heard, DOB in secretions and maintain >Do CPT >To manage client’s
 Productive cough some cases orthopnea is normal breathing condition non-
 Tachypnea RR=(43 observed. pattern. >Give bronchodilators as pharmacologically
cpm) ordered (e.g.BIONEB) >To pharmacologically
 Productive Cough >Refer for any abnormal manage client’s
changes in the body condition
> The pt manifested >To medically manage
the ff. any complication.

Restlessness
Cyanosis

BPN

 Impaired Gas Exchange r/t retained secretions 2° BPN

 Risk for Impaired Tissue Perfusion r/t Impaired Gas Exchange 2° BPN