You are on page 1of 6

III.

Nursing Care Plan


Nursing Priority No. 1: Ineffective airway clearance related to excessive accumulation of secretions secondary to Pneumonia
ASSESSMENT

NURSING

PLANNING

INTERVENTION

RATIONALE

EVALUATION

DIAGNOSIS
Subjective:
Nahihirapan ng

Ineffective

After 8 hours of

airway

nursing

anak ko dahil sa

clearance

intervention the

sipon at plema

related to

patient will be

nya as

excessive

able to have

verbalized by

accumulation

patent airway as

the mother

of secretions

manifested by:

huminga ang

secondary to
Objective:
> RR= 38 cpm
> crackles

Pneumonia

- RR within
normal range
- Decrease
crackles heard

auscultation

upon

mucoid nasal
discharge
> productive
cough
> Irritable

>To develop trust and

GOAL MET

cooperation of the

After 8 hours of

client

effective nursing

> Monitor vital signs

intervention the

especially the

> To obtain baseline

respiratory rate

data

patient is able to
have patent airway
as manifested by:

> Monitor for feeding

heard upon

> presence of

>Establish rapport

auscultation
- Decrease

intolerance,

> These factors may - RR = 32 cpm

abdominal distention

compromise airway

and emotional

crackles upon
auscultation

stressor

presence of
mucoid nasal

>Advise frequent

>To mobilize secretion

change in position

presence of
nasal discharge

>Encourage to
increase oral/milk
intake

> To liquefy secretion

discharge

>Perform

>To moisten

nebulization as

secretions and

ordered

alleviate congestion

>Perform back

> To mechanically

tapping or Chest

dislodge secretions

Physiotherapy after

from the bronchial

each nebulization

walls

> Administer
Salinase nasal drops
1-2 gtts/nostril q4-6

Nursing Priority No. 2: Impaired gas exchange related to collection of secretions affecting oxygen exchange across alveolar
membrane
ASSESSMENT

NURSING

PLANNING

INTERVENTION

RATIONALE

EVALUATION

DIAGNOSIS
GOAL MET
S/O:

Impaired gas

After 8 hour of

exchange

nursing

related to

intervention

collection of

the client will

secretions

demonstrate

heard upon

affecting

improved

auscultation

oxygen

ventilation and

exchange

adequate

Objective:
> RR= 40 cpm
> crackles

> irregular and


shallow
breathing

> presence of
mucoid
nasal
discharge

>To develop trust

After 8 hour of

and cooperation of

nursing intervention

the client

the client will


demonstrate

> Monitor vital signs

> To obtain baseline

especially the

data

improved ventilation
and adequate

respiratory rate depth

oxygenation as

and ease.

manifested by:

across alveolar oxygenation as


membrane

manifested by:

> (+) nasal


flaring

>Establish rapport

- RR within
normal range
- ( - ) nasal
flaring

> Observe skin color

>Determine

- RR = 38 cpm

and capillary refill.

circulatory

- ( - ) nasal flaring

adequacy, which is

- Decreased

necessary for gas

crackles heard

exchange to

upon auscultation

tissues.

- Decreased

and

crackles

productive

heard upon

>Rest prevents

cough

auscultation

> Encourage rest.

tissue oxygen
demand and

> Irritable

enhances tissue
oxygen perfusion.
>Facilitates
>Assist with nebulizer

liquefaction and

treatments.

removal of
secretions.

> To mechanically
>Perform back

dislodge secretions

tapping or Chest

from the bronchial

Physiotherapy after

walls

each nebulization

> Administer Salinase


nasal drops 1-2
gtts/nostril q4-6

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

Subjective:

Altered body

After 8 hours of

Medyo mainit

temperature

nursing

siya pag

related to

intervention the

hinahawakan

bacterial

patients body

invasion in the

Temperature will

lungs as

be stabled from

manifested by

37.9C to 37.5C

ko as
verbalized by
the mother

body
Objective:

temperature

>Febrile:

higher than

38.2C

normal

INTERVENTION

>Establish rapport

>To develop trust

EVALUATION

GOAL MET

and cooperation of
the client

After 8 hours of

> Monitor vital signs

> To obtain baseline

effective nursing

especially Temperature

data

intervention the
Patients Body

>Perform a tepid sponge

> Sponge bath with

bath

warm water
evaporates off his

>Encourage to wear

skin, thus cooling off

loose clothes

the patient.

>skin is warm
to touch

RATIONALE

>Encourage patient to
take rest.

> Administer
Paracetamol drops
( Tempra) 1ml for T
37.8 c

Temperature
becomes stabled to
37.2C