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Nursing care plan

Problem # 1
Cough with Phlegm

Subjective Data
-mother verbalized “nahihirapan baby ko umubo”

Objective Data
-RR is 76 bpm(N-30-50 BPM) -cough with phlegm -difficulty in breathing -raising of shoulder when breathing

Nursing Diagnosis Ineffective airway clearance related to increased amount of secretion, chest pain and fatigue and weakness as evidenced by difficulty of breathing

Secretion of phlegm may contribute to obstruction in airway clearance thus resulting to difficulty in breathing Goal or Objective
After 1 hour of nursing intervention, patient will be able to demonstrate patent airway as evidenced by ability to cough up secretions and deep breathe.


1. Assist patient with or instruct effective deep breathing and coughing with upright position.
Promote lung expansion, remove secretions.

2. Encourage adequate fluid intake.
Adequate hydration aids in keeping secretions loose and enhances expectoration.

3. Assess for pain or discomfort and medicate on a routine basis and prior to breathing exercises.

Encourages the patient to cough more effectively and breathe more deeply to prevent respiratory insufficiency.

4. Put patient in semi-fowler’s position.
Promotes better lung expansion and improved air exchange.

5. Assist with oral hygiene every 4 hours or as needed.
Decrease oral flora

6. Maintain rest periods.
Prevent fatigue.

7. Suction if needed.
It clears secretion.

Goal met. Patient was able to breathe well. He demonstrated proper coughing technique and was able to secrete phlegm.

Problem # 2
Difficulty of breathing

Subjective Data -Father verbalized”my son cant breath so fast”

Objective Data -RR is 76 (N:30-50bpm) -forceful cough -difficulty in breathing -raising of shoulder when breathing

Nursing Diagnosis Impaired gas exchange related to ventilation perfusion imbalance Exchange of gases is being affected due to bronchospasm resulting from constriction of bronchial smooth muscle

Goal or Objective After 2 hours of nursing intervention, patient will be able to have airway clearance and increased respiratory response as evidenced by having respiratory rate within normal range, which is 30-50 breaths per minute.

Intervention Independent

1.Position patient in proper body alignment for optimal breathing pattern. Allows lung excursion and chest expansion. (Gulanick,1998:28) 2. Tech patient appropriate breathing, coughing, and splinting technique. Facilitate adequate clearance of secretions. (Ibid.) 3. Explain effects of wearing restrictive clothes.
So that exertion is not compromised. (Ibid.)

4. Pace activities and schedule rest periods.
Even simple activities (such as breathing) during bed rest can cause increase oxygen consumption. (Ibid.)

Goal partially met. Patient’s respiration rate was decreased to 70 bpm. He was able to remove secretions and verbalized improvement in comfort.

Problem #3 Body Weakness

Subjective Data
-father verbalized”my son getting thinner”

Objective Data -weak hand grip -fatigabilty -poor sleep

Nursing Diagnosis Activity intolerance related to decreased muscle strength secondary to poor nutritional intake as evidenced by weak hand grip

Goal or Objective
After 2 hours of nursing intervention, patient will be able to decrease fatigue level as evidence by relaxed appearance.

Intervention Independent 1. Encourage several rest periods. During rest, energy is conserved and levels are replenished several shorter rest periods may be more beneficial than one longer rest period. (Smeltzer, 2004:336) 2. Encourage patient to ask assistance when doing something to reduce workload. It conserves energy. (Ibid) 3. Encourage adequate protein and calorie intake. Protein and calorie depletion decreases activity tolerance. (Ibid) 4. Encourage use of relaxation techniques. Promotion of relaxation and psychological rest decreases physical fatigue. (Ibid) 5. Increase total hour of night time sleep. Sleep helps to restore energy levels. (Ibid)

Goal met. Patient appeared to be relaxed. Patient verbalized of comfort.

Problem # 4 Risk for infection

Subjective Data -father verbalized”somengtimes forgot to wash my hand if i carry my son”

Objective Data -hyperthermia -nosoconial infection -poor hygiene

Nursing Diagnosis Risk for infection related nosoconial infection secondary due to poor hygine Nosoconial infection is an infection whose development is favoured by a hospital environment, such as one acquired by a patient during a hospital visit or one developing among hospital staff such as handwashing.

Goal or Objective
After 2 hours of nursing intervention, patient will be able to demonstrate normal temperature and preventive measures to avoid infection.

Intervention Independent 1. Monitor vital sings especially temperature. Increased body temperature indicates infection. Sings and symptoms of infection may be diminished in the host if there is subsequent initiation therapy. (Smeltzer, 2004: 334)

2. Avoid contact with people who have known or recent infection.
Preventing contact with pathogens helps prevent infection. (Ibid.) 3. Instruct all personnel to do hand hygiene before and after entering the room. Hands are significant source of contamination. (Ibid.) 4. Each day: change drinking water, denture cleaning fluids and other equipments containing water. Stagnant water is a source of infection. (Ibid.) 5. Limit visitors. To reduce number of organism in patient and reduce transmission of pathogens. (Ibid.)

6. Encourage coughing and deep breathing.
Measures reduce secretions in the lungs when stasis occurs can cause urinary and respiratory infection. (Ibid.)

7. Administer mouth care.
Limit bacterial growth and promote patient comfort. (Ibid.)

Goal met. Patient’s temperature was 36.8 °C. Patient parents also performed hand washing but still assisted by wife.