Nursing Care Plan

NURSING CARE PLAN (1) Assessment S>Ø O > w/ productive cough of whitish in color, non-mucoid > use of accessory muscle noted > tachypneic = > tachycardic = > pale and weak in appearance > restlessness > irritable > crackles on ® upper lung upon auscultation Nsg Dx Ineffective airway clearance R/T pulmonary disease as manifested by presence of mucus secretions.

Planning Within 4 hours of nursing intervention, the patient will manage to maintain a patent airway.

Intervention INDEPENDENT: 1.) Place patient into high fowler’s position R > maximize lung expansion and decrease respiratory effort 2.) Advise mother to do back tapping R > helps to manually loosen or dislodge secretions 3.) Assess airway patency R > helps to check for any obstruction or accumulation of fluids and maintain adequate airway patency 4.) Auscultate lung fields, noting areas of decrease or absence of airflow and adventitious breath sounds R > To identify areas of consolidation and determine possible bronchospasm or obstruction

SE: 5.) Advise to increase fluid intake R > keeps mucus secretions moist and easier to expel 6.) Maintain a relaxed, calm and non-stimulating environment R > Establish optimal rest/ sleep pattern.

Expected Outcome After 4 hours of nursing intervention, the patient manage to achieve patent airway as evidenced by: a. respiratory rate is within normal range b. mucus section is decrease c. coughing is minimize

COLLABORATIVE: 1.) Suction as order by the physician R > Help the body rid the lungs of mucous thus allowing easier breathing and agility. 2.) Administer the following medications as order: a. Bronchodilator R> Increases lumen size of the tracheobronchial tree, thus decreasing resistance to airflow and improving oxygen delivery. b. Oxygen therapy R> increase oxygen saturation in tissues where the saturation levels are too low due to illness or injury. c. Antibiotics R> to treat underlying cause of the condition

NURSING CARE PLAN (2) Assessment S>Ø O > elevated body temperature = > weak in appearance > warm to touch > tachycardic = > flushy face > irritable Nsg Dx Hyperthermia R/T disease process SE:

Planning Within 4 hours of nursing intervention, the patient’s temperature will be normalize or turn to a more manageable manner

Intervention INDEPENDENT: 1.) Monitor v/s especially body temperature R> recognizing the increase in temperature can help determine if there is abnormalities in the patient. 2.) Advise SO to do TSB R> helps lower body temperature 3.) Assess patient’s neurologic response R> helps note level of consciousness, reaction to stimuli, pupil reaction, presence of posturing or seizures that can affect the patient 4.) Provide proper ventilation R> Patients need enough oxygen supply that help to normalize body temperature. 5.) Advise to loosen clothing R> Heat should be release especially I groin and axillae area. 6.) Maintain bed rest R> reduce metabolic demands or oxygen consumption COLLABORATIVE: 1.) Administer the following as order:

Expected Outcome After 4 hours of nursing intervention, the patient’s temperature will be normalize as evidence by decrease of temperature from °C to °C

a. Oxygen therapy R> helps offset increase oxygen demands and consumption b. Antipyretic drug R> elimination of fever will interfere with its enhancement of immune response c. Antibiotic drugs R> to treat underlying cause of the condition

NURSING CARE PLAN (3) Assessment S>Ø O > weak in appearance > irritable > restlessness > lethargic > tachycardic = > tachypneic = Nsg Dx Impaired Gas exchange R/T presence of secretions affecting oxygen across alveolar membrane SE:

Planning Within 4 hours of nursing intervention, The patient will improve ventilation and adequate oxygenation of tissues by arterial blood gases within patient’s normal limits

Intervention INDEPENDENT: 1.) Assess respiratory rate, depth and ease. R> Manifestations of respiratory distress as dependent on indicative of the degree of lung involvement and underlying general status. 2.) Monitor body temperature R> High fever greatly increases metabolic demands and oxygen consumption and alter cellular oxygenation 3.) Monitor for skin color, mucous membranes, nailbeds, and noting presence of peripheral or central cyanosis R> Cyanosis of nailbeds may indicate vasoconstriction. However, cyanosis of mucous membranes and around the mouth is indicative of systemic hypoxemia 4.) Assess patient’s neurologic response R> helps note level of consciousness, reaction to stimuli, pupil reaction, presence of posturing or seizures that can affect the patient 5.) Assess heart rate and rhythm R> may represent a response to hypoxemia 6.) Elevate head of the bed and change position frequently

Expected Outcome After 4 hours of nursing intervention, the patient will be able to improve ventilation and oxygenation as evidence by: a. decrease of RR from b. decrease of CR from

R> promotes optimal lung expansion and expectorations or clearing of secretions 7.) Encourage adequate rest and limit activities R> promote calm and restful environment COLLABORATIVE: 1.) Administer medications as order. > corticosteroids > antibiotics > bronchodilators > expectorant 2.) Monitor ABG’s and pulse oximetry R> follows progress of disease process and facilitates alterations in pulmonary therapy