Assessment Subjective: Nahihirapan huminga yong anak ko. Avb the mothet of the pt.

Objective: > Vital ign taken a follo! : "#: $%& bpm ##:'' cpm > (O) > u e of acce ory mu cle !hen breathing > *+, crackle upon au cultation > $-& ec capillary refill > .ry lip > re tle appearance > *+, irritability > !ith pro.uctive cough > (/ of Acute bronchiti

Nursing Diagnosis 0neffective air!ay clearance r1t e/ce ive ecretion in the air!ay pa age .

Scientific Explanation 0nva ion of micro organi m *bacteria, 0rritation of the mucu membrane Accumulation of ecretion Ob truction of the air!ay pa age 0neffective air!ay clearance

Nursing Intervention At the en. of the 23 $. 7onitore. vital hift4 the patient !ill ign . be able to maintain &. Au cultate. improve air!ay breath oun. . clearance aeb: %. "o itione. > v1 !ithin normal patient in a emirange fo!ler8 po ition. "#: 56-$&6 bpm ##: &6-%6 cpm > le ene. .ifficulty of breathing > .ecrea e u e of '. 0n tructe. acce ory mu cle mother to increa e > *+, e/pectoration flui. intake of the of ecretion patient. > $-& ec capillary refill 9. :"; .one every > *-, .ry lip after nebuli<ation. > .ecrea e re tle ne > *-, irritability :ollaborative: =. Nebuli<ation .one a or.ere..

Nursing Goal

Rationale $. >or ba eline .ata. &. ;o note tatu an. progre . %. "romoting che t e/pan ion4 ai. in the mobili<ation an. e/pectoration of ecretion . '. ;o help loo en up the ecretion 9. ;o mobili<e ecretion in the lung .

Evaluation @oal partially met. After the 2-hour hift4 patient !ere a e e. to have maintaine. an. improve air!ay clearance aeb: > v1 !ithin normal range "#: $$' bpm ##: %&cpm > le ene. .ifficulty of breathing > .ecrea e u e of acce ory mu cle > *+, e/pectoration of ecretion > $-& ec capillary refill > *-, .ry lip > .ecrea e re tle ne > *+, irritability

=. >acilitate li?uefaction an. removal of ecretion .

Assessment Subjective: Nilalagnat ya e. aeb the mothet of the patient.

Nursing Diagnosis Ayperthermia r1t inflammatory proce an. infection

Scientific Explanation 0nfection Aypothalamu )o.y generate arachi.onic aci.1pro taglan.in

Nursing Goal Short ;erm @oal: After &-% hour of nur ing intervention4 patient !ill ho! improvement in hi health con.ition aeb: > ;emp: %=.9- %5 : > *-, flu he. kin > *-, !arm to touch > *-, irritability > *-, pale an. !eak appearance > *-, lo of appetite > *-, .iaphore i

Nursing Intervention $. 7onitor v1 of the patient. &. "rovi.e. tepi. ponge bath. %. B/po e kin to air or to provi.e proper ventilation. '. Bncourage SO of the patient to increa e flui. intake of !ater an. fruit juice . 9. A.vi e. SO of the patient to re.uce phy ical activity an. increa e fre?uency of re t perio.. =. "rovi.e. oral an. na al care.

Rationale $. >or ba eline .ata. &. ;o .ecrea e bo.y temperature through con.uction. %. ;o provi.e a.e?uate ventilation. '. ;o meet the increa e metabolic .eman. an. to prevent .ehy.ration. 9. ;o limit heat pro.uction.

Evaluation @oal partially met. After & hour of nur ing intervention4 patient ho!e. improvement in hi health con.ition aeb: > ;emp: %5.& : > *-, flu he. kin > *-, !arm to touch > *+, irritability > *-, pale an. !eak appearance > *-, lo of appetite > *-, .iaphore i

Objective: > ;emp: %2 : > !ith flu he. kin > !arm to touch > irritable > !eak an. pale appearance > lo of appetite > *+, .iaphore i

Actively me.iate. the central re pon e Blevate. hypothalamic et point )o.y initiate heat an. con ervation inclu.ing va ocon triction piloerection >ever

=. ;o keep mucou membrane moi t4 prevent .ry an. cracke. lip an. for infection control.

:ollaborative: 5. A.mini tere. antipyretic .rug a pre cribe. by the .octor.

5. Ai. in the re.uction of the temperature of the patient.

Assessment Subjective: Ayon ma.ali yang mapago.. Avb the mothetr of the patient. Objective: > vital ign taken a follo! : ;emp: %2 : "#: $%& bpm ##:'' cpm > !1 (O) > $-& ec capillary refill > !eak an. pale appearance > ea y fatigability > *+, pro.uctive cough > patient ju t lying or ju t itting on be. all .ay > !ith loo e tool an. pa e. tool 9=/ a .ay > no appetite > an 0V> of (96.%C Na:l > !ith (/ of Acute bronchiti A@B !ith ome .ehy.ration

Nursing Diagnosis Activity intolerance r1t general !eakne

Scientific Explanation 0ncrea e con umption of nutrient by pathogen :ellular .eprivation of nutrient :ellular tarvation Deakne Activity intolerance

Nursing Goal After &-% .ay of nur ing intervention4 patient !ill .emon trate a mea urable increa e in tolerance to activity aeb: > vital ign of: "#: 56-$&6 bpm ##: &6-%6 cpm > *-, (O) > $-& capillary refill > patient !ill be able to !alk in i.e the !ar. > patient !ill be able to eat > increa e appetite

Nursing Intervention $. 7onitor vital ign . &. Bvaluate patient8 re pon e to activity. Note report of .y pnea4 increa e. !eakne 1 fatigue4 an. fatigue4 an. change in vital ign .uring an. after activitie . %. "rovi.e a ?uite environment an. limit vi itor .uring acute pha e a in.icate..

Rationale $. >or ba eline .ata. &. #e.uce tre an. e/ce timulation4 promoting re t.

Evaluation @oal met. After % .ay of nur ing intervention patient .emon trate. a mea urable increa e in tolerance to activity aeb > vital ign of: "#: $$2 bpm ##: &2 cpm > *-, (O) > $-& capillary refill > patient !a playful an. !a !alking !ithin the !ar. !ith the a i tance of the gran.mother > patient !a able to con ume meal erve. > increa e. appetite

'. A i t patient to a ume comfortable po ition for re t1 leep. 9. A i t !ith elf-care activitie a nece ary. "rovi.e for progre ive increa e in activitie .uring recovery pha e. =. A.vi e. SO of the patient to increa e flui. intake of the patient.

%. )e.re t i maintaine. .uring acute acute pha e to .ecrea e metabolic .eman. 4 thu con erving energy for healing. '. "atient may be comfortable !ith hea. elevate.4 leeping in a chair. 9. 7inimi<e e/hau tion an. help balance o/ygen upply an. .eman.. =. >or the replacement of flui. lo .