Assessment Subjective: Ubo siya ng ubo pero walang lumalabas na plema, as verbalized by the patients mother

Diagnosis Ineffective airway clearance related to excessive mucus production in the bronchioles

Planning At the end of 2 hours, the patient will be able to manifest improved airway clearance as evidenced by: RR of 20-30 cpm Decreased crackles, bilateral Expectoration of sputum

Intervention INDEPENDENT: Assessed the patients respiratory pattern Positioned patient in moderate High Back Rest Provided a well ventilated and quiet environment Provided adequate rest period

Rationale

provides baseline data to gauge the efficacy of nursing intervention

Evaluation Goal met. At the end of 2 hours, the patient was able to manifest improved airway clearance as evidenced by: RR of 29 cpm Decrease crackles, bilateral May kasamang plema yung laway niya, as verbalized by the mother

Objective: (+) bilateral crackles RR- 36 cpm Productive cough retained sputum

this position maximizes lung expansion

to promote relaxation

rest will prevent fluid loss from too much exertion exacerbated by increase work of breathing to liquefy copious secretions and to prevent accumulation of sputum in the tracheobronchial tree thus prevents further obstruction chest physiotherapy technique utilizes forces

Advised SO to increase fluid intake of patient

Performed chest tapping theraphy

every after due nebulization

of gravity and motion to facilitate secretion removal

DEPENDENT: Nebulization given as ordered ( Salbutamol; 2.5 ml q6) nebulization facilitates bronchodilation for faster and better expectoration of secretions

Maintained oxygen @ 2 lpm Administered Acetylcysteine 50 mg TID as ordered

to prevent suppression of respiratory drive to liquefy copious secretions and to prevent accumulation of sputum in the tracheobronchial tree thus prevents further obstruction

Assessment Subjective: Parang nahihirapan siyang huminga dahil sa sipon niya, as verbalized by the patients mother

Diagnosis Ineffective breathing pattern related to constricted bronchioles

Planning At the end of 1 hour, the patient will be able to manifest improved breathing pattern as evidenced by a decrease in RR (20-30 cpm)

Interventions INDEPENDENT: Elevated the patients head at about 30 by placing pillows underneath Encouraged position of comfort such as Side-lying position Maintained calm attitude while dealing with pt. and SO Provided chest vibration

Rationale To promote physiological/ psychological ease of maximal inspiration

Evaluation Goal Met. At the end of 1 hour, the patient was able to manifest improved breathing pattern as evidenced by a decrease in RR, from 36 cpm to 29 cpm.

Objective: RR of 36 cpm (+) cough and colds

To promote comfort and maintain airway

To limit level of irritability

To mechanically dislodge secretions

DEPENDENT: Nebulization given as ordered (Salbutamol 2.5 ml q6 )

To decrease inflammatory response and to widen the diameters of the bronchioles for better air passage

Assessment Risk factors: Age- 1 year old Presence of infection Previous episode of febrile seizure SO stated, Nung nagseizure siya sa hospital, hindi ko alam kung anong gagawin ko kaya napaiyak nalang ako.

Diagnosis Risk for Injury

Planning At the end of 30 minutes, the SO will be able to verbalize at least 3 seizure precautions

Intervention Established rapport with SO

Rationale To obtain a trusting relationship for better nursing outcome

Educated SO about seizure precautions such as: Always keep the side rails up Instructed SO to buzz To notify healthcare providers quickly about episodes of seizure Emphasized importance of keeping suction and oxygen at bedside After an episode of seizure, suction any secretions to prevent aspiration and maintain airway patency It allows the tongue to fall forward to facilitate drainage of saliva and mucus To ensure patients safety and prevent falls

Evaluation Goal met. At the end of 30 minutes, the patients SO was able to verbalize all the seizure precautions.

During an episode of seizure, place the patient on one side with head flexed forward Do not attempt to restrain the patient during seizure

Muscular contractions are strong and restrain can produce injury A rise in temperature can precipitate convulsions

Monitored patients vital signs, especially temperature Monitored patient at intervals

To update patients current status

Assessment Subjective: Mainit siya, tinignan ko yung temperature niya eh 37.9 ang nakuha ko as verbalized by the patients mother.

Diagnosis Hyperthermia related to increase pyrogens in the body

Planning At the end of 1 hour, the patients body temperature will decrease from hyperthermia to normal body temperature ( 36.537.5)

Interventions INDEPENDENT: Monitor vital signs especially temperature Perform TSB

Rationale Serves as baseline data.

Evaluation

To reduce body temperature through the process of conduction and evaporation To prevent dehydration and support circulating blood volume. To provide conducive place to rest. To provide ventilation and promote release of heat through conduction To reduce metabolic demands/ oxygen consumption Increase metabolic rate and diaphoresis associated with fever cause loss of body fluid Pharmacologic measures to decrease the body temperature

Encourage to increase oral fluid intake Objective: T- 37.9 Warmth to touch Flushed skin

Provide safe & quiet environment

Loosen tight clothing

Provide bed rest

Dependent Administer IV fluids as ordered Administer medications as ordered Paracetamol 1 amp IV PRN