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 >Establish rapport >To develop trust and GOAL MET
huminga ang airway nursing cooperation of the After 8 hours of
anak ko dahil sa clearance intervention the client effective nursing
sipon at plema related to patient will be > Monitor vital signs intervention the
nya” as excessive able to have especially the > To obtain baseline patient is able to
verbalized by accumulation patent airway as respiratory rate data have patent airway
the mother of secretions manifested by: as manifested by:
secondary to > Monitor for feeding
Objective: Pneumonia - RR within intolerance, > These factors may - RR = 32 cpm
> RR= 38 cpm normal range abdominal distention compromise airway - crackles upon
> crackles - Decrease and emotional auscultation
heard upon crackles heard stressor - presence of
auscultation upon mucoid nasal
> presence of auscultation >Advise frequent >To mobilize secretion discharge
mucoid nasal - Decrease change in position
discharge presence of
> productive nasal discharge >Encourage to > To liquefy secretion
cough increase oral/milk
> Irritable intake
>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 >Establish rapport >To develop trust After 8 hour of
exchange nursing and cooperation of nursing intervention
Objective: related to intervention the client the client will
> RR= 40 cpm collection of the client will demonstrate
> crackles secretions demonstrate > Monitor vital signs > To obtain baseline improved ventilation
heard upon affecting improved especially the data and adequate
auscultation oxygen ventilation and respiratory rate depth oxygenation as
> irregular and exchange adequate and ease. manifested by:
shallow across alveolar oxygenation as
breathing membrane manifested by: > Observe skin color >Determine - RR = 38 cpm
> (+) nasal and capillary refill. circulatory - ( - ) nasal flaring
flaring - RR within adequacy, which is - Decreased
> presence of normal range necessary for gas crackles heard
mucoid - ( - ) nasal exchange to upon auscultation
nasal flaring tissues.
discharge - 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 PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: Altered body After 8 hours of >Establish rapport >To develop trust GOAL MET
“ Medyo mainit temperature nursing and cooperation of
siya pag related to intervention the the client After 8 hours of
hinahawakan bacterial patient’s body > Monitor vital signs > To obtain baseline effective nursing
ko” as invasion in the Temperature will especially Temperature data intervention the
verbalized by lungs as be stabled from Patients Body
the mother manifested by 37.9°C to 37.5°C >Perform a tepid sponge > Sponge bath with Temperature
body bath warm water becomes stabled to
Objective: temperature evaporates off his 37.2°C
>Febrile: higher than >Encourage to wear skin, thus cooling off
38.2°C normal loose clothes the patient.
>skin is warm
to touch >Encourage patient to
take rest.

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