NURSING CARE PLAN
Name of the Patient: Y__
Civil Status: N/A_ Religion: N/A
Address: Plaridel, Bulacan
Date of Admission: March 05, 202
CUES
Subjective/ Objective
Objective Cues:
Rales upon Ausculation
Deep inspiration and
expiration, accompanied with
nasal flaring.
Chest X-ray shows hazed
with fibro nodular infiltrates
at the inner zone of both
lungs with enlarged hilar
nodes
Temp: 38.8-degree Celsius
Pulse Rate: 145 bpm
Respiratory Rate: 43bpm
Subjective Cues:
Mother states that the infant
is irritable, difficulty in
breathing and cries
vigorously
Age: 8 Months Sex: Female
Rm/Bed No.N/A
Diagnosis: Pneumonia Rating: ___________________________________________________
Nursing Diagnosis Nursing Objectives Nursing Interventions
Impaired breathing pattern After 5 hours of nursing
related to rales and fibro intervention the patient
nodular infiltrates in the inner would be able to:
zone of the both lungs as 1. The patient would
evidenced by the deep effectively release
breathing and evident nasal the increased levels
flaring. of mucosa in the
lungs.
2. Breathing would
lessen in difficulty
and RR and PR
would reach near
normal levels.
3. Increased oxygen
intake due to
lessened difficulty in
breathing and
lessened
obstructions in the
air pathway.
Name of Student: Vizconde, Ehreiz Raiden C.
Area: Baliuag District Hospital Level/ Block: Block 2-A
Date Submitted: March 08, 2022
Rationale
1. Perform percussion The vibration dislodges the
on the back and sputum in alveoli, allowing it
front area in order to to be expectorated during
disengage the coughing.
sputum.
2. Place the patient in The Semi-Fowler’s position
a Semi-Fowler’s allows the lung capacity to
position in order to increase due to the lowering
increase lung of the diaphragm that causes
capacity. an increase in tidal volume
of the lungs. While
promoting effective breathing
3. Increasing the fluid The increase in the fluid
intake absorbed by intake would help reduce the
the child. viscosity of the mucus,
allowing it to dislodge more
easily. In addition to helping
replace the fluid loss from
the fever due to diaphoresis
Expected Outcomes
1. There is a decrease
in the levels of
mucosa in the lungs
due to effective
release.
2. RR and PR is
decreased and
breathing pattern is
not entirely
constricted due to
the clearer airway
pathways.
3. Increased oxygen
intake due to more
effective breathing
and lessened nasal
flaring is evident.
4. Temperature would 4. Performing a TSB The TSB is an effective non- 4. Temperature has
decrease alongside on the child to help therapeutic method, decreased and is
pulse rate. decrease the alongside drinking water, already reaching the
5. The mother would temperature and because it helps us lessen normal range.
be knowledgeable reduce irritability. the internal body
upon performing temperature when cleaning. 5. Mother is
techniques in Due to the vasodilation and knowledgeable on
expectorating opening of pores that causes the breathing
mucus, breathing that causes the techniques, health
techniques and hypothalamus to react, promotion and TSB
promoting the child’s which lessens the procedures. Such
health through temperature set point. that she was able to
promoting a healthy demonstrate the
5. Teaching the mother
environment and The different breathing said procedures.
breathing
non-therapeutic techniques should be though
techniques like
interventions for to increase inspiratory
pursed lip-breathing,
fever. capacity and tidal volume if
effective coughing.
the child’s problem were to
Deep breathing,
exist again in the near future.
Sputum
This would help the mother
physiotherapy and
become better equipped in
application of TSB.
lessening the impaired gas
Alongside the
exchange present.
promotion of healthy
environment by
In addition, the teaching of
distancing the child
the TSB would greatly affect
from smoke.
the child in the effect of
health promotion. With the
proper distance and security
from smoke, because smoke
can cause irritation to the
bronchioles and alveoli.
Causing increased mucus
production and unproductive
cough in the initial stages.