ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALIZE EVALUATION

SUBJECTIVE: Ineffective airway After 4 hours of nursing Monitored respirations Indicative of respiratory After 4 hours of nursing
clearance related to intervention the patient and breath sounds, noting distress and/or intervention the goal was
“Umitim po yung buong foreign body in airway as will be able to maintain rate and sounds (e.g., accumulation of met that the patient was
katawan” as verbalized by evidenced by adventitious
airway patency tachypnea, stridor, secretions. be able to maintain
the mother breath sound and skin
discoloration. crackles, or wheezes) airway patency
OBJECTIVE:

 Bluish skin
discoloration Monitored infant/ child That may compromise
 Murmurs airway
for feeding intolerance,
V/S taken as follows: abdominal distention, and
emotional stressors
PR:115
RR: 26
T°: 38.4
SpO²: 99 To open or maintain open
Positioned head
airway in an at-rest or
appropriately for age and
compromised individual
condition

To prevent vomiting with

Positioned appropriately
aspiration into lungs
(e.g., head of bed
elevated, side lying) and
discourage use of oil-
based products around
nose
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Ineffective Breathing After 8 hours of nursing Independent: Goal met, after 8 hours of
SUBJECTIVE: Pattern related to intervention, patients nursing intervention the
decreased lung expansion respiratory pattern will 1. Monitored and To gain baseline data patients airway breathing
“Umitim po yung buong be effective without record vital signs is cleared
as evidenced by bluish
katawan” as verbalized by causing fatigue
the mother skin discoloration. 2. Inspected thorax It determines adequacy of
for symmetry of breathing
respiratory
movement
OBJECTIVE:
3. Noted rate and Rate may be faster or
 Bluish skin depth of slower than usual. In
discoloration respirations, infants and younger
 Murmurs counting for 1 children, rate increases
full minute, if dramatically relative to
rate is irregular. anxiety, crying, fever, or
V/S taken as follows: disease.

4. Auscultated and Abnormal breath sounds

PR:115 percuss chest, are indicative of
RR: 26 describing numerous problems and
T°: 38.4 presence, must be evaluated further
SpO²: 99 absence, and
character of
breath sounds

5. Noted color of If pallor, duskiness,

skin and/or cyanosis are
present, supplemental
oxygen and/or other
interventions may be
required. (Refer to ND
impaired Gas Exchange
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: Hyperthermia related to After 2 hours of nursing Independent: After 2 hours of nursing
Nangitim ang kanyang positive bacterial intervention, the patient’s intervention, the goal was
katawan at nilagnat as infection as manifested by body temperature will Established rapport to  To build trust met that the patient’s
verbalized by the mother flushed and warm to return to its normal range mother to gain trust and and cooperation. body temperature will
touch skin cooperation. This helps create return to its normal range
a positive and
OBJECTIVE: supportive
environment for
Skin is warm to touch the child’s care.

PR: 115
RR: 26
T°: 38.4 Promote surface cooling  This can help
SpO²: 99% by means of undressing lower the child’s
(heat loss by radiation body
and conduction) temperature and
manage fever.

Demonstrate on how to  The wet cloth

do a proper tepid sponge helps cool the
bath using wet and dry body through
cloth. evaporation,
while the dry
cloth helps
prevent chilling.