NURSING CARE PLAN IN PEDIA WARD

Name: Tipo, Elijah Louise Address: Purok 4, Biong, Gigmoto, Catanduanes

Age: 4 months old Sex: Male

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Ineffective airway SHORT TERM  Monitor vital  To provide SHORT TERM
The mother clearance related to GOALS: signs, the baseline data and GOALS:
verbalized “ inflammation and respiration and further treatment
nasakitan increased secretions LONG TERM GOAL: breath sound. and management. LONG TERM GOALS:
maginhawa yong as evidenced by After 3 days of Note the breath After 3 days of
baby ko dahil sa presence of nursing interventions rate and sounds. nursing
sipon buda ubo” secretions, the patient would be interventions:
productive cough, able:  Position the  It promotes
Objective: and increased work patient with the enhanced lung
 Use of of breathing. Maintain patent head is elevated expansion Patent airway
accessory airway as evidence (semi fowlers maintained as
muscles by child being free of position) evidenced by child
 Oxygen in secretions, easy being free of
use via nasal work of breathing  Administer  To increase secretions, easy work
cannula and respiratory rate supplemental oxygen level for of breathing and
within parameters oxygen as effective gas respiratory rate
for age. ordered and exchange and withing parameters
humidify oxygen perfusion. And to for age.
help liquify
secretion for ease
in clearance.

 Suction with bulb  Patients may

 syringe or via require
nasopharyngeal naso/tracheal/oral
catheter as suctioning to clear
needed. the airway,
especially in the
presence of an
artificial airway or
if the patient is
unable to cough
or swallow.

 Administered  To promotes
nebulization as clearance of
ordered. secretion.

 Perform and  To mobilize

taught the secretions.
mother on how
to do the chest
physiotherapy.
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Altered breathing SHORT TERM GOALS:  Assess the  This will help to
Parents complaints pattern, dyspnea After 2 hours of breathing pattern know the rate
that their can’t take related to excessive nursing intervention or the patient. and rhythm and
breath properly . mucus the patient will respiration
improve breathing  Provide
Objective: pattern comfortable  Providing
 Weakness position for the comfortable
noted patient. position helps to
 Use of increase thoracic
accessory space.
muscles  Administer
during medications
inspiration is according to the
observed doctors order.
 O2 sat = 95%
with oxygen
at 4 LPM