Nursing Care Plan 1st Priority Sampoli,Jannelle Karen (Pneumonia) Assessment Subjective:

"Nahihirapang huminga ang anak ko" as verbalized by the mother. Objective: Long Term: Restlessness Pale color RR= 63 cpm Adventitious breath sounds (crackles, wheezes sounds) Nursing Diagnosis Ineffective Airway Clearance may be related to decreased lung expansion (fluid & air accumulation), pain inflammatory process, possibly evidenced by dyspnea, tachypnea, cough and ABG's. After 1 day of nursing intervention the mother of the baby demonstrate behaviours to improve or maintain clear airway. Observe for signs of respiratory distress (increased rate, restlessness/anxiety use of accessory muscle for breathing. To assess changes. Note complication. Position head appropriate for age and condition. to open or maintain open airway in at rest or compromised individual. Dependent: Administer Analgesics. To improve cough when pain is inhibiting effort. Give expectorants & bronchodillators as ordered. After 1 day of nursing intervention the mother of the baby has demonstrated behaviours to improve or maintain clear airway. Goals met.

Planning Short Term:

After 4 hours of nursing intervention the patient maintain airway patency.

Intervention/Rationale Independent:
Monitor Respirations & breathe sounds (e.g. tachypnea, crackles, wheezes. To maintain adequate patent airway.

Evaluation Short Term:

After 4 hours of nursing intervention the patient was able maintain airway patency. Goals met. Long Term:

To mobilize secretions. Collaborative: Monitor/document serial chest x-ray, ABG's, pulse oxymetry reading. To assess changes, note complications. Assist with procedures (e.g. bronchoscopy, tracheostomy). To clear/maintain open airway.

2nd Priority Impaired gas exchange

Assessment Subjective:
"Napansin kong namumutla ang anak ko" as verbalized by the mother Objective Pale,

Planning Short Term:

After 15 minutes of nursing intervention the patient will be able to have a respiratory rate with-in normal range Long Term:

Intervention/Rationale Independent:
Assess patient's respiratory rate This will serve as respiratory function Monitor vital signs, note for changes in cardiac rate Hypoxia is associated with signs of increased breathing effort Oxygen saturation To determine oxygen sufficiency Elevate head or position the patient appropriately To facilitate airway efficiency Maintain adequate intake and output For mobilization of secretions Collaborative Recommend the mother to stimulate the

Evaluation
Goals partially met as evidence by:

Nasal flaring, Dyspnea with a respiratory rate of 63 cpm, Tackycardia with a pulse rate of 158 bpm Nursing Diagnosis Impaired gas exchange related to alveolar capillary changes as manifested by abnormal skin color After 30 minutes of nursing intervention the patient will be able to maintain a normal breathing pattern of 30-60 cpm

baby to cry once in a while To enhance lung expansion and to maximize oxygenation Dependent: Sunctioning as ordered To maintain airway Provide supplemental oxygen at the lowest concentration as ordered/to increase inhalation of oxygen concentration Nebulizer as ordered For bronco dilation

3rd Priority Acute Pain

Assessment Subjective:
"Umiiyak siya pag nadidiinan ko ang tiyan nya" as verbalized by the mother of the patient. Face scale: 7/10 Objective: irritability crying abdominal tenderness cool fingertips/toes RR: 63 cpm PR: 158 bpm Nursing Diagnosis: Acute pain related to exessive use of accessory muscle of breathing and abdominal colic as manifested by irritability and crying

Planning Short Term:

After 15 minutes of nursing intervention, the mother of the patient will be able to demonstrate use of relaxation skills and diversional activities to reduce pain of the patient. Long Term: After 1 hour of nursing intervention, the patient will be able to demonstrate actions that pain is reduced from 7/103/10.

Intervention/Rationale Evaluation Independent: Short Term:

Determine cause of pain to access precipitating contributory factors Ask mother to identify behaviours that may indicate pain since the client is unable to verbalize feelings. Instruct the mother on use of relaxation technique such as back rub to ease pain. Collaborative: Coordinate with the mother on proper way of positioning of the patient. Familiarity of the patient with the mother will facilitate cooperation Dependent: After 15 minutes of nursing intervention, the mother was able to demonstrate use of relaxation skills and diversional activities to reduce pain of the patient. Goals met. Long Term: After 1 hour of nursing intervention, the patient is still irritable and crying because medication cannot be given stat due to interval of last dose administered Goals met.

Administer analgesics as ordered To relieve pain thru proper medication 4th Priority Hyperthermia

Assessment Subjective:
"Mainit sya pag hinahawakan ko" as verbvalized by the mother Objective: Increase in body temperature above the normal range Warm to touch V/S as follows: PR: 180 RR: 58 TEMP: 38.5 Nursing Diagnosis: Hyperthermia related to body temperature elevated above normal range

Planning Short Term:

After 1 hour of nursing intervention the patient will be able to maintain core temperature within normal range. Long Term: After 4 hours of nursing intervention the patient will be able to demonstrate free of complications such as neurological damage.

Intervention/Rationale Evaluation Independent: Short Term:

Note chronological and developmental age of client Children are more susceptible to heart stroke. Monitore core temperature. To evaluate degree of hyperthermia Tepid Sponge Bath the patient To decrease body temperature thru the principle of heat transfer via conduction and evaporation Collaborative: Educate mother of patient on proper way of performing sponge bath. For mother to be able to do the procedure properly at home in cases medications cannot be provided at immediately After 1 hour of nursing intervention the patient was able to maintain core temperature within normal range. Goals met. Long Term: After 4 hours of nursing intervention the patient was able to demonstrate free of complications such as neurological damage. Goals met

Report to the NOD significant increase in temperature

For NOD to assess if administration of antipyretic is possible Dependent: Administer antipyretics, orally/rectally as ordered. To assist with measure to reduce body temperature.