Nursing Problems:

Acute Pain
Cough
DOB
Excessive mucus secretions
 Assessment Diagnosis Planning Interventions Scientific Rationale Evaluation

Subjective Data: Impaired Gas After 2 weeks of Independent: After 2 weeks of

Exchange related nursing 1. Assess the infant’s 1. A decreased level of nursing
“Galisud siya ug decreased interventions: status via Vital signs. consciousness can be an interventions:
ginhawa.” - as oxygenation as indirect measurement of
verbalized by the evidenced by 1. The infant will impaired oxygenation. GOAL MET
mother. shortness of have a respiratory
breath. rate within the 2. Note the presence of 2. Because it can be related to 1. The infant's
Objective Data: normal range conditions that can cause multiple factors, including respiratory rate is
10/07/23 (30-60 breaths per or be associated in some prematurity, infant, within the
@2:16 pm minute) way with gas exchange aspirations, decrease lung normal range of
problems. compliance, excessive 55 bpm (normal
V/S as follows: 2. The infant will thickness secretions. range for infant:
P: 134 bpm have an oxygen 30-60 bpm).
R: 71 bpm saturation of
O2Sat: 94% 96-100% without 3. Assess energy level 3. It guides in addressing these 2. The infant's
supplemental and activity tolerance, symptoms and improving the oxygen
-SOB oxygen noting evidence of patient's quality of life despite saturation is at
fatigue, weakness, and oxygenation challenges. 97% without
3. The infant will problems with sleep that supplemental
show improved are associated with oxygen.
ventilation and diminished oxygenation.
adequate 3. The infant has
oxygenation of shown improved
tissues by arterial- ventilation and
Assessment Diagnosis Planning Interventions Scientific Rationale Evaluation

blood gases within 4. Encourage frequent 4. Feeding provides the adequate

infant usual feeding to prevent necessary energy for oxygenation of
parameters and dehydration and promote respiratory muscle function. tissues as
absence of energy for breathing. Infants use a significant evidenced by
symptoms of amount of energy for arterial blood
Respiratory breathing, and adequate gases within
distress. nutrition ensures they have the infant usual
energy required for optimal parameters and
respiratory effort. absence of
symptoms of
5. Encourage and 5. Skin-to-skin contact has respiratory
facilitate skin-to-skin been shown to reduce stress distress.
contact between the infant levels in both infants and
and the mother to mothers. Reduced stress
promote bonding and contributes to better
reduce stress. respiratory stability in infants
and enhances the bonding
experience between the infant
and the mother.

6. Monitor oxygen 6. Regular monitoring allows

saturation and respiratory for the early detection of
rate every 2 hours. changes in oxygen saturation
and respiratory rate, enabling-
Assessment Diagnosis Planning Interventions Scientific Rationale Evaluation

prompt intervention in case of

respiratory distress or
compromise. This is crucial
for infants, as their respiratory
systems are still developing
and may be more susceptible
to issues.

7. Encourage the mother 7. Breastfeeding requires a

to have adequate rest and significant amount of energy.
nutrition to support Lactating mothers have higher
breastfeeding. caloric needs to support the
production of breast milk,
which is rich in nutrients and
helps the immune system of
the infant which is essential
for the infant's growth and
development.

8. Maintain a calm 8. A calm and quiet

environment and quiet environment can help reduce
environment to decrease the infant's stress levels.
respiratory distress. Lower stress levels contribute
to decreased oxygen-
Assessment Diagnosis Planning Interventions
9. Keep environment
allergen and pollutant free
10. Evaluate the changes
in sleep pattern.
Dependent:
1. Administer medication
as indicated (e.g. nasal
cannula) as prescribed.
2. Monitor and instruct
mother in therapeutic
effect and adverse effect
as well as interaction of
drug therapy.
Scientific Rationale Evaluation
consumption, which is
especially important for
infants who may have limited
respiratory reserves.
9. To prevent irritant effect of
dust and chemicals on
airways.
10. Which may indicate night
time airway incompetence.
1.To prevent and control
symptoms, reduces frequency
and severity of exacerbations.
2. To inform the mother and so
that she knows the potency
and efficacy of the
administered drug.
Assessment Diagnosis Planning Interventions Scientific Rationale Evaluation

3. Administer prescribe 3. To help reduce bacterial

antibiotics to treat the infection that is associated in
underlying infection if mucus plug.
mucus plug is associated
with bacterial infection.

Collaborative:
1. Encourage frequent 1. To promote optimal chest
position changes. expansion, and mobilization of
secretions also to promote
oxygen diffusion.

2. Encourage the parent(s) 2. To reduce health risk and

to prevent the infant in prevent further decline in lung
interacting with smokers function for the infant.
and recommend smoking
cessation programs if
needed.

3. Discuss home oxygen 3. To ensure client’s safety,

therapy and safety especially when used on an
measures, when home infant.
oxygen is implemented.
 Assessment Diagnosis Planning Interventions Scientific Rationale Evaluation

Subjective Data: Ineffective After 2 weeks of Independent: After 2 weeks of

Airway nursing 1. Assess behaviors 1. This information is nursing
“Ug moubo siya Clearance related interventions: indicating respiratory essential for identifying interventions:
kai gahi ug to mucus plug as 1. Patient will distress (ex: wide-eyed, potential airway problems,
moutong.” - as evidenced by the show no signs of irritable, or restlessness). providing baseline level of GOAL MET
verbalized by the presence of cough respiratory care needed, and influencing
mother. and difficulty in distress. choice of interventions to the 1. Patient shows
breathing. mother or significant others. no signs of
Objective Data: 2. Patient will respiratory
10/09/23 maintain airway 2. Monitor respirations 2. Indicative of respiratory distress.
@7:00 am patency and breath sounds, noting distress and/or accumulation
rate and sounds (ex: of secretions. 2. Patient
V/S as follows: 3. Patient will tachypnea, stridor, maintains airway
P: 149 bpm show crackles, or wheezes) patency.
R: 63 bpm absence/reduction
O2Sat: 97% of congestion with 3. Position head 3. To open or maintain airway 3. There is
breath sounds appropriately for age and in an at-rest or compromised absence/reduction
-SOB clearing, noiseless condition. individual. of congestion
-grunting respirations and with breath
-presence of improved oxygen 4. Monitor infant for 4. To check for a sounds clearing,
mucus change feeding intolerance, and compromised airway. noiseless
abdominal distention. respirations and
4. Significant improved oxygen
others will- change
Assessment Diagnosis Planning Interventions Scientific Rationale Evaluation

verbalize an 5. Position the patient 5. An upright position 4. Mother

understanding of upright as tolerated. facilitates maximum lung verbalizes an
cause(s) and expansion and reduced understanding of
therapeutic abdominal pressure. cause(s) and
management therapeutic
regiment 6. Keep environment 6. Keeping the environment management
allergen free (ex: dust, free from allergen factors can regiment
feather pillows, or smoke) help reduce/alleviate
according to individual respiratory distress.
situation.

7. Auscultate breath 7. To ascertain current status

sounds and asses air and note effects of treatment
movement. in clearing airways.

8. Monitor vital signs, 8. To detect any abnormalities

noting changes in in case of possible changes
respiratory rate and heart and report to physician if
rate. necessary.

9. Observe for 9. To determine educational

signs/symptoms of and support needs
infection.
Assessment Diagnosis Planning Interventions Scientific Rationale Evaluation

10. Monitor changes and 10. To reduce risk of

report any unusualities. atelectasis (collapse of the
lungs) and to enhance lung
expansion.

Dependent:
1. Prepare for/assist with 1. To identify causative/
appropriate testing (ex: precipitating factors.
pulmonary function or
sleep studies

2. Assist with procedures. 2. To evaluate for a clea open

(ex:chest X-ray) airway.

3. Administer nebule 3. To relax smooth respiratory

medications or musculature, and mobilize
medications in general secretions.
(ex: salbutamol) that is
prescribed by physician.

4. Administer saline nasal 4. To help moisturize and

drops or spray. loosen nasal secretions,
making it easier to-
Assessment Diagnosis Planning Interventions
Collaborative:
1. Parents and caregivers
should be educated on
signs and symptoms to
seek treatment promptly.
(ex: signs of infection
such as a fever or change
in mucus color and
amount as well as any
changes to respiratory rate
or pattern)
2. Advise the mother in
preventing the child in
social interaction or
crowded area.
3. Encourage parents to
seek medical health care
when there’s any unusual
observations.
Scientific Rationale Evaluation
clear the airways.
1. Educating the
caregivers/significant others
allows them to understand and
have ideas on preventative
measures.
2. To prevent the child getting
any microbes or particles that
will cause respiratory distress.
3. To assess the infant's
progress, monitor for any
recurrence of mucus plugs,
and ensure that appropriate
measures are in place for
ongoing care and support.