ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

BACKGROUND
Subjective: Ineffective Infiltration of Short term: Independent: Independent: Short term:
-“mariingan airway clearance bacteria or virus 1. Demonstrate the 1. To help improve
kam tingah rabii related to through the nose After 8 hours of importance of back breathing for After 8 hours, the client
na, maangsan increased mucus or mouth nursing tapping after coughing adequate airway and responds and engages
ken agmangit secretions as interventions, the and even after good respiratory with reduced difficulty in
isunah” as evidenced by Pathogens client will be at nebulization. function. respiration, coughing,
verbalized by phlegm/mucus reaching lung ease with the however is still a
the patient’s retention and parameters absence of mucus 2. Instruct deep presence of rales upon
mother frequent Goblet cells and with clear breath breathing exercises 2. To maximize effort auscultation. Therefore,
-colds coughing. cilia that line the sounds, noiseless and proper coughing to ease difficulty in the goal is partially met.
airway respiration and techniques. breathing and give
improved gas ways of proper Long term:
Objective: exchange. management in
Traps foreign
- cough clearance of After 2 days, the client,
substances
-ineffective Long term: 3. Keep environment secretions. together with his parent
including bacteria
sputum free from dust, smoke 3. To promote a shows positive behavior
and viruses via
elimination After 2 days of and other potential setting conducive for in engagement to enhance
mucus secretions
-nasal flaring nursing allergens. faster recovery and clear airway of the
-restlessness interventions, the comfort. patient. They engage in
-slightly Accumulation of client, together 4. Increase fluid discussion of proper
irritable phlegm causing with the parents intake within the4. Hydration can help medication treatments.
-presence of obstruction to will be able to cardiac tolerance.prevent accumulation Thus, the goal is met.
rales upon airway passages demonstrate Encourage/provide of viscous secretions
auscultation behaviors to warm versus cold and improve secretion
-Vital signs Ineffective improve or liquids as appropriate. clearance.
taken: Airway Clearance maintain clear
Temperature: airway of the 5. Position head
36.1°C patient. appropriately for age 5. To maintain open
PR: 128 bpm Reference from: and condition. airway in an at-rest
RR: 38 cpm https://www.ncb individual.
O2 Sat: 95% i.nl 6.Encourage/provide
m.nih.gov/book opportunities for rest; 6. To reduce fatigue
s/NB limit activities to level
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Dependent:
1. Assist in proper Dependent:
nebulization of the 1. To correct
patient as prescribed. misconceptions of
proper procedures in
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
BACKGROUND
Subjective: Hyperthermia Infiltration of Short term: Independent: Independent: Short term:
-crying as related to bacteria or virus 1. Initiate means of 1. To increase heat
reported by increased through the nose After 8 hours of tepid sponge bath and loss by evaporation After 8 hours, the client
mother. metabolic or mouth nursing damp towel or cloth at and conduction. had a recorded
-decreased response due to interventions, the client’s forehead. temperature of 36°C.
appetite as infection as Pathogens client will be able Therefore, the goal is
reported by evidenced by reaching lung to have a 2. Promote 2. Evaporation is met.
mother. elevated parameters temperature comfortable decreased by
temperature of Cytokines released below 38.5 °C. environment and environmental factors Long term:
38.5 °C. as an inflammatory ventilation. of high humidity.
response Long term: This allows increase After 2 days, the patient
Objective: of heat loss by the had a body temperature of
-warm to touch After 2 days of client, and initiate 36.1°C, which is still
Vasodilation for
-slightly nursing comfort. within the normal range.
faster
irritable interventions, the 3. Encourage to use The client is not warm to
transportation of
-restlessness client will appropriate clothing 3. To minimize touch and had improved
leukocytes to
-Vital signs maintain and and blankets. possible shivering, its eating diet. Therefore,
affected area
taken: demonstrate a promote rapid core the goal is met.
Temperature: stable core cooling, and helps in
38.5 °C. Heat production temperature thermoregulation of
PR: 134 bpm within the normal body.
RR: 34 cpm range. 4. Administer
O2 Sat: 98% Ineffective replacement fluids and 4. To support
thermoregulation electrolytes. Also circulating volume
by the monitor for the and tissue perfusion.
hypothalamus patient’s fluid intake It aids in preventing
and fluid loss such as possible dehydration.
urine and sweating.
Hyperthermia
5. Instruct high-calorie
diet to improve 5. To meet increased
Reference from: nutrition metabolic demands.
https://www.my
med. 6. Maintain bedrest
com/diseasesco 6. To reduce
nditions/hyperth metabolic demands
er and oxygen
mia#:~:text=Ex 7. Reassess vital signs consumption.
cess regularly and record 7. This information is
results. essential for
identifying potential
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
BACKGROUND
Subjective: Impaired gas Reference from: Short term: Independent: Independent: Short term:
Infiltration of
https://simplenu
-“mariingan exchange related bacteria or virus 1. Encourage deep 1. To promote
kam tingah rabii to decreased rsing.ph/risk- After 12 hours of breathing exercises, optimal chestAfter 12 hours, the client
through the nose
for-impaired-
na, maangsan alveolar- or mouth nursing back tapping and expansion, showed improved
ken agmangit capillary gas-exchange- interventions, the proper coughing mobilization ofbreathing, however is still
isunah” as membrane as care- client will be able techniques. secretions and oxygen observed with slight
Pathogens
verbalized by evidenced by reaching lung to show signs of diffusion. respiratory distress.
the patient’s mucus retention, parameters improved Therefore, the goal is
mother frequent Goblet cells and ventilation with 2. Keep environment 2. To reduce irritant partially met.
coughing and cilia that line the absence of allergen and pollutant effect of dust and
difficulty in airway respiratory free chemicals on airways. Long term:
breathing. distress.
Objective: 3. Elevate head of bed 3. Elevation orAfter 2 days, the parent
Traps foreign
-cough Long term: and position client upright positionshowed active
substances
-slightly appropriately. facilitates respiratoryengagement in discussion
including bacteria
irritable After 1 day of function. of proper treatment
and viruses via
-nasal flaring nursing 4. Maintain fluid regimens and
mucus secretions
-Vital signs interventions, the intake within the 4. To mobilize interventions. Therefore,
taken: client, together cardiac tolerance. secretions effectively the goal is met.
Temperature: Accumulation of with the parents
36.1°C mucus into the will verbalize and 5. Position head
PR: 128 bpm interstitial space participate in appropriately for age 5. To maintain open
RR: 38 cpm and alveoli treatment and condition. airway in an at-rest
O2 Sat: 95% regimens, and 6.Encourage adequate individual.
Deficit oxygen at appropriate rest and limit activities
the alveolar- interventions. to within client 6. To limit oxygen
capillary tolerance. needs and
membrane consumption.
Dependent:
Impaired carbon 1. Administer
dioxide medications and
elimination therapy (salbutamol, Dependent:
nasal spray) as 1. To correct
Impaired gas prescribed by the misconceptions of
exchange doctor proper procedures in
administering
nebulization. Further
mobilize secretions
and relax respiratory
smooth muscles.