NURSING CARE PLAN

Patient’s Name: Simone Phillips Age & Gender: 4-month old female Chief Complaint: Respiratory Distress and cough
Name of Student Nurse: Quirimit, Darwin N. Birthdate: June 3, 2022
Admitting Diagnosis: Respiratory Distress, pneunomia role out pertusis Level/Block/Group: 3BSN-11
Address: Arellano St, Dapupan City, Pangasinan
Hospital/Area: UPang Mock Hospital
Date of Confinement: June 3, 2022 Clinical Instructor: Ma’am M.M.N.E Date: June 3, 2022

CASE SCENARIO:
Simone Phillips is a 4-month old female admitted to PICU 7 days ago with cough and respiratory distress. Patient presented in respiratory failure with central
cyanosis, apnea and poor air movement, required intubation and mechanical ventilation for 2 days. Her condition was managed with IV fluids, bronchodilator
nebulized treatments and antibiotic therapy. She was extubated 3 days ago and weaned from 35% oxygen, to 2 liters NC to room air yesterday. She was
stable and transferred to the Pediatric Ward 2 days ago.
Current status: room air, taking oral feedings and has a PIV in the right antecubital to saline lock. Nebulized bronchodilators are given every 4 hours.
Discharge is planned in next 24 hours. Today she has been increasingly fussy and beginning to show signs of respiratory distress.
Immunizations: Hepatitis B at birth. No other vaccines given.
 ASSESSMENT NURSING ANALYSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
SUBJECTIVE: Ineffective breathing SHORT TERM GOAL: INDEPENDENT: 1. To obtain the - The goal was met since,
“Nararamdaman ko po pattern is define as the - After 2-3 hours of 1. always establish cooperation and trust of after 2-3 hours of nursing
na nahihirapang huminga inspiration and/or nursing interventions, the rapport. patients. intervention, the infant
ang aking anak at ako po expiration that does not infant will cough coughed effectively and
ay natatakot.” as provide adequate effectively and make 2. Provide peaceful 2.Peacefull environment made distinct breath
verbalized by the patient ventilation. distinct breath noises. environment to the will create relaxation of noises.
mother. patient. the patient
- The parent or watcher -The goal was
OBJECTIVE: of the patient should be 3. Vital signs of the 3. To establish a baseline fulfilledsince the patient
- central cyanosis educated about the patient should constantly or watcher were able to
- apnea breathing techniques be monitored. identify strategies to
- poor air movement when the patient reduce discomfort and
Review of Systems: experiences breathing 4. Assist the patient in a 4. This will provides
felt more calm as a result.
 CNS wnl distress. comfortable posture, proper placement aids in
 Cardiovascular Sinus elevate the head of the the prevention of back - The patient looks more
tachycardia - The parents or watchers bed or have the client sit problems, gives support comfortable and tranquil
 Pulmonary may notice that their up in a chair. and balance, and most than before the day he
tachypnea, crackles patient will grow more importantly allows the was admitted to the
on auscultation, relaxed and quiet as the 5. Use supplementary patient to breathe and hospital.
moderate retractions, breathing discomfort is humidification, such as a relax appropriately.
nasal flare and reduced. nebulizer.
secretions 5. Providing
 Renal/Hepatic wnl LONG TERM GOAL: humidification to a
- After 24hrs of nursing patient can help them - the objectives have
 Gastrointestinal wnl been accomplished since
 Endocrine wnl intervention, The parent's breathe easier if they
patient may notice signs have asthma, allergies, or the patient since after 24
 Heme/Coag wnl of nursing intervention,
 Musculoskeletal wnl of improvement in are suffering from a
breathing patterns, such respiratory illness like a the parent has been
 Integument wnl discharged from hospital
 Developmental Hx as relaxed, normal cold.
breathing. and depth, as and noticed that her
Lifts head, smiles child’s breathing pattern
hands to mouth well as the lack of apnea
and central cyanosis, they has improved such as
 Psychiatric Hx N/A relaxed, normal
Social Hx Lives with will clear for discharge.
breathing. and depth, as
parents, no siblings
 Alternative/ DEPENDENT: well as the lack of apnea
Complementary 1. Administer proper 1. the variety of drugs can and central cyanosis.
Medicine Hx N/A medicine according to the be utilized to reduce
 Medication allergies: doctor's orders. mucus and enchance
None known breathing pattern.
Reaction: 2. Keep an eye on the
 Food/other allergies: patient's oxygen 2. Pulse oximetry is a
None known saturation as directed by useful tool for identifying
Reaction: the doctor. oxygenation changes in
 Laboratory, the clinical setting.
Diagnostic Study 3. Prepare for the
Results: Na: 140 necessity for intubation 3. To avoid
mEq/L K: 4,5 mEq/L and mechanical decompensation,
Cl: 98 mEq/L Hgb: ventilation as ordered intubation and positive-
11g/dl Hct: 37% pressure ventilation are
performed to maintain
the client's breathing and
NURSING DIAGNOSIS ventilation stable.
Ineffective breathing
pattern related to
hyperventilation as
evidence by central
cyanosis, apnea and
poor air management