Assessment

Subjective:
Objective:
tachycardia
Restlessness
Nasal flaring
Use of accessory
muscle
Presence of
Mechanical
ventilator
Abnormal arterial
pH
Pale in appearance
DOB
V/S:
BP: 100/70
RR: 45
PR: 184
T: 38
Nursing Care Plan

Diagnosis
Impaired Gas
exchange r/t
altered delivery
of inspired
oxygen and air
trapping

Planning
After 4 hours of
nursing
intervention he
patient will
demonstrate
improved
ventilation and
adequate
oxygenation of
tissues as
evidence by
normal capillary
refill test.

Intervention
Monitor respiratory
status every 4
hours, blood gas
analysis and
input/output.

Rationale
To identify the
indication
toward
progress or
deviations
from the client.

Place patient in
semi fowler
position.

Encourage adequate
rest, promote calm
and restful
environment.

Helps limit
oxygen needs
and
consumption.

Keep environment
allergen and
pollutants free.

To reduce
irritant effect
to dust and
chemicals on
airway

Upright
position
allowing good
lung
expansion.

Evaluation
After 4 hours of
providing nursing
intervention the
patient was
demonstrated
improved
ventilation and
adequate
oxygenation of
tissues as evidence
by normal
capillary refill test.

Assessment
Subjective:
Nahihirapan
siyang
huminga
Objective:
Productive
cough
Wheezing
Crackles on R
and L bronchi
Restlessness
V/S:
BP: 100/70
PR: 184
RR: 45
T: 38

Diagnosis
Ineffective airway
clearance r/t
retained secretions
in the bronchi and
airway constriction

Planning
After 4 hours if
nursing
intervention
patients secretions
will lessen

Intervention
Keep
environment
allergen and
pollutants free.

Rationale
To reduce
irritant effect to
dust and
chemicals on
airway

Encourage to
rest

To reduce
fatigue

Elevate head of
bed

To facilitate
lung expansion

Change position
every 2 hours

To take
advantage of
the gravity to
decrease
pressure on the
diaphragm and
enhance
drainage.

Monitor child
for feeding
intolerance and
abdomen

To avoid
compromised
airway

Evaluation
After 4 hours of
nursing intervention
clients secretion
was lessen.

distension.

Assessment
Subjective:
Objective:
Dry lips
Warm skin
Tachycardia
Tachypnea
V/S:
BP: 100/70
PR:184
RR:45
T: 38.0

Diagnosis
Fluid volume
deficit r/t

Planning
After 4 hours of
nursing
intervention the
patient will
maintain fluid
volume at a
functional level as
evidenced by stable
vital signs.

Assist in
suctioning

Intervention

To maintain
clear and open
airway.
Rationale

Evaluation