Subjective: Vital signs:

“GI SIP-ON AKONG ANAK UG PAS2 Temp: 37.5 C

IYANG GINHAWA” AS VERBALIZED RR: 40bpm
BY PATIENT SO
HR: 200bpm
Weight: 26.5 lb
Height: 37.3’’

NURSING DIAGNOSIS

Ineffective airway clearance related to tracheobronchial and nasal secretions as evidence

by “Rhinorrhea or runny nose”
PLANNING
Short term: at the end of 2 hours duty of the hospital patient SO will verbalize
understanding of the current situation.

Long-term: Patient will be able to cough up secretions and perform coughing and deep-
breathing exercises.
INTERVENTION RATIONALE
Assess respiratory status for rate, depth, Changes may vary from minimal to
ease, use of accessory muscles, and work of extreme caused by bronchial swelling,
breathing increased mucus secretions caused by
oversecretion of goblet cells and
tracheobronchial infection, narrowing of
air passageways, and presence of other
disease states that complicates the current
condition.
Auscultate the lung fields for the presence Wheezing is caused by squeezing of air
of wheezes, crackles (rales), rhonchi, or past the narrowed airways during
decreased breath sounds. expiration which is caused by
bronchospasms, edema, and secretions
obstructing the airways. Crackles or rales,
result from consolidation of leukocytes and
fibrin in the lung causing an infection or by
fluid accumulation in the lungs. Decreased
breath sounds may indicate alveolar
collapse with little to no air exchange in
the lung area being auscultated and usually
 results in poor ventilation.
Assess patient for pallor or cyanosis, Although not a reliable indicator of the
especially to nail beds and around the loss of airway patency, this may indicate
mouth. hypoxemia. Cyanosis does not occur until
a level of 5 grams of reduced
hemoglobin/100 ml of blood in the
superficial capillaries is reached.
Position patient in high Fowler’s or semi- To promote maximal lung expansion.
Fowler’s position, if possible.
Encourage deep breathing exercises and Assists in lung expansion, as well as
coughing exercises every 2 hours. dislodgement of secretions for easier
expectoration.
Suction patient if needed. The patient may be too weak or fatigued to
remove own secretions.
Teach the patient or significant others Promotes increased expiratory pressure
regarding splinting abdomen with a pillow and helps to decrease discomfort.
during cough efforts.
Encourage fluids, up to 3-4 L/day unless Provides hydration and helps to thin
contraindicated. secretions for easier mobilization and
removal.
Dependent: Promotes relaxation of bronchial smooth
muscles to decrease spasms, dilates
Administer bronchodilators as ordered
airways to improve ventilation, and
maximizes air exchange.
Administer oxygen as ordered. Monitor Providing supplemental oxygen benefits
oxygen saturation by pulse oximetry, and the patient.High-level oxygen can cause
notify the physician of readings <90% or as severe damage to tissues, oxygen toxicity,
prescribed by the physician. increases in A-a gradients,
microatelectasis, and ARDS. Oximetry
readings of 90 correlate with PaO2 of 60
mmHg and levels below 60 mmHg do not
allow for adequate perfusion to tissues and
vital organs.
Zinacef 100 mg every 6 hours IV (ANST). Treat a wide variety of bacterial infections.
Cefuroxime ( Zinacef) 100mg every 6
hours ANST( ) as prescribed.
Evaluation :
Subjective: Vital signs:

“paspas kayo iyang ginhawa ug murag gi Temp: 37.5 C

kapoy na siya” as verbalized by patient SO RR: 40bpm

HR: 200bpm
Weight: 26.5 lb
Height: 37.3’’
NURSING DIAGNOSIS

Ineffective breathing pattern related to retained secretions as evidence by RR above the

normal range

PLANNING
Short term:
At the end of 2 hours duty patient will be able to verbalized understanding of the
problem.
Long-term:
At the end of 2 days duty patient will maintain RR within normal limits.

INTERVENTION RATIONALE
Assess patient’s respiratory status every 2 Manifestation of respiratory distress
to 4 hours as indicated and notify any include shortness of breath, tachypnea,
abnormal findings. changes in mental status and the use of
accessory muscles.
Auscultate breath sounds every 2 to 4 hours Decreased breath sounds, crackles,
as indicated. wheezes, and rhonchi can be observed and
must be reported promptly for
immediatement treatment.
Place a pillow when the client is sleeping. Provides adequate lung expansion while
sleeping.
Instruct how to splint the chest wall with a Promotes physiological ease of maximal
pillow for comfort during coughing and inspiration.
elevation of head over the body as
appropriate.
Dependent: These medications is given for patient with
Forced expiratory volume in 1 second
Inhaled corticosteroids such as budesonide
(FEV1) at less than 30% whose history of
(Pulmicort Flexhaler), mometasone
exacerbations are poorly managed by the
(Asmanex Twisthaler), beclomethasone
use of long-acting bronchodilators.
(Qvar RediHaler), fluticasone (Flovent
HFA)
Long-acting bronchodilators such as Decreases hyperinflation, lessen bronchial
salmeterol, perforomist (formoterol), obstruction and enhances lung emptying.
bambuterol, indacaterol
Evaluation :
At the end of series nursing intervention
patient was able to breath normally and
main RR within the normal range. Goal
fully met

Subjective: Vital signs:

“ge helantantan siya” as verbalized by Temp: 37.5 C

patient SO RR: 40bpm
HR: 200bpm
Weight: 26.5 lb
Height: 37.3’’
NURSING DIAGNOSIS

Risk for infection related to Inadequate primary defenses (decreased ciliary action, stasis
of secretions)
PLANNING
Short term:
At the end of 2 hours duty, patient SO will verbalized understanding of the problem.
Long-term:
At the end of 2 days duty, patient SO Demonstrate techniques, lifestyle changes to
promote safe environment.

INTERVENTION RATIONALE
Monitor temperature. Fever may be present because of infection
or dehydration.
Review the importance of breathing These activities promote mobilization and
exercises, effective cough, frequent position expectoration of secretions to reduce the
changes, and adequate fluid intake. risk of developing a pulmonary infection.
Observe color, character, odor of sputum. Odorous, yellow, or greenish secretions
suggest the presence of pulmonary
infection.
Demonstrate and assist the patient in the Prevents spread of fluid-borne pathogens
disposal of tissues and sputum. Stress
proper handwashing (nurse and patient),
and use gloves when handling or disposing
of tissues, sputum containers.
Limit visitors; provide masks as indicated. Reduces potential for exposure to
infectious illnesses such as upper
respiratory infection (URI).
Encourage a balance between activity and Reduces oxygen consumption or demand
rest. imbalance, and improves patient’s
resistance to infection, promoting healing.
Recommend rinsing mouth with water and Reduces the localized immunosuppressive
spitting, not swallowing, or use of a spacer effect of drug and risk of oral candidiasis.
on the mouthpiece of inhaled
corticosteroids.
Dependent:

Administer antimicrobials as indicated.

Evaluation :
At the end of series nursing intervention
patient was able to breath normally and
temperature in normal range.
BON, JEBRENTH APPLE M.

GENERAL OBJECTIVES:

(KNOWLEDGE, SKILLS, ATTITUDE)

At the end of 16 hours duty at the hospital

I will be able to:

Use my nursing knowledge in assessing the with the right attitude assess thoroughly and
be able to come up nursing diagnosis, series of interventions and care plan for the patient.

SPECIFIC OBJECTIVES:

(KNOWLEDGE, SKILLS, ATTITUDE)

At the end of 16hrs hours duty @ the hospital

I will be able to:

SKILLS:

 Accurately perform a thorough physical assessment of the patient

 To be able to assess the physician and making sure that the medical as well as the
emotional needs of the patient are adequately met throughout the entire hospital
stay.

 To be able to document everything

KNOWLEDGE:

 To be able to identify between normal and high-risk preschool age

 To be able to provide patient education, do medical tasks, support the physician in
emergencies, but also provide emotional support.
 Recognize the contributing factors associated with the development of nursing
diagnosis.

ATTITUDE:
  Respect patients’ rights at all times
 Patience is a virtue, be approachable.
 Understand patient’s complaints and listen very well.

DAILY PLAN OF ACTIVITIES

TIME ACTIVITY REMARKS

6am-7:30am Arrival time
Preparation

7:30am-8:00am Prayer
announcement

Establishing rapport to the patient

Vital signs taking
8am-9am
History takings
Physical assessments
Patient 1 rounds
Vital signs taking
9:00am-10:00am
History takings
Physical assessment
10:00am-11:30am Nursing diagnosis
Patient 2 rounds

11:30am-12:30nn Nurses notes

12:00nn-1pm Break

1:00pm-2pm Perform nursing intervention

 Patient 3 rounds

2pm-3pm Establishing rapport to the patient

Vital signs taking
History takings
Physical assessment
3pm-4pm Diagnosis
intervention

4pm-5pm Nurses notes

Evaluation
Do after care