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Independent:
Subjective: Hyperthermia After 1 hr of ÿ Monitor Vital ÷ For baseline Goal Partially Met
³Nilalagnat ata related to infection nursing signs data, needed After 1 hr of
ako, ang init ng as manifested by intervention, the especially for ongoing nursing
pakiramdam ko´ body temperature patient¶s body body comparison intervention, the
as verbalized by of 38.8°C, warm temperature will temperature patient¶s body
the patient flushed skin and decrease from ÿ Monitor I & O ÷ To assess temperature
diaphoresis 38.8°C down to fluid loss decreased from
37.5°C ÿ Promote 38.8°C down to
Objective: surface ÷ Heat loss by 37.7°C
÷ Body temp per cooling by radiation and
axillae 38.8°C means of conduction
÷ Diaphoresis wearing
÷ Warm flushed cotton shirts
skin or if
necessary by
means of
undressing
ÿ Perform TSB ÷ Heat loss by
evaporation
ÿ Encourage to ÷ To prevent
increase fluid dehydration
intake
ÿ Encourage ÷ To avoid
adequate rest fatigue
periods
Dependent:
ÿ Administer ÷ Acts on the
anti pyretic hypothalamus
drugs to decrease
(Paracetamol temperature
500 mg q4)
      
  
  
 
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Independent:
Subjective: Ineffective After 2 hrs of ÿ Monitor Vital ÷ For baseline Goal Met
³Nahihirapan breathing pattern nursing signs data, needed After 2 hrs of
akong huminga´ related to intervention, the especially for ongoing nursing
as verbalized by incomple lung patient will body comparison intervention, the
the patient expansion develop effective temperature ÷ To provide patient developed
secondary to fluid breathing pattern ÿ Position the maximum effective breathing
accumulation on as evidenced by client on lung pattern as
Objective: the pleural space decreased RR semi-fowler¶s expansion evidenced by
÷ Tachypnea as manifested by from 28 down to position decreased RR
÷ RR 28 RR of 28, 20 ÿ Instruct deep ÷ To promote from 28 down to
÷ Use of tachypnea, use of breathing deep 19
accessory accessory exercises inspiration
muscles muscles and ÿ Provide ÷ Prevent
difficulty of adequate rest dyspnea
breathing periods resulting from
fatigue
ÿ Use pain ÷ To allow the
management patient to
breathe deep
Dependent:
ÿ Administer ÷ Dilates
bronchodilator bronchi tree
as ordered by for maximum
the physician ventilation
(salbutamol)
      
  
  
 
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Independent:
Subjective: Ineffective airway After 1 ½ hrs of ÿ Monitor Vital ÷ For baseline Goal Partially Met
³nahihirapan clearance related nursing signs data, needed After 1 ½ hrs of
akong huminga, at to increased intervention, the especially for ongoing nursing
parang punong mucous patient will have body comparison intervention, the
puno ng plema production effective airway temperature ÷ To provide patient had
ang dibdib ko´ as secondary to clearance as ÿ Position the maximum effective airway
verbalized by the infection as evidenced by client on lung clearance as
patient manifested by RR decrease in RR semi-fowler¶s expansion evidenced by
of 32, tachypnea, from 32 down to position decrease in RR
and presence of 20 ÿ Instruct deep ÷ To promote from 32 down to
Objective: crackles upon breathing deep 26
÷ Tachypnea auscultation exercises inspiration
÷ RR 32 ÿ Instruct ÷ To expel
÷ Use of coughing secretions
accessory exercises
muscles ÿ Increase oral ÷ To dilute
÷ Crackles fluid intake secretions
present upon ÿ Teach SO on ÷ To aid the
auscultation of performing patient move
the chest CPT and expel
secretions
Dependent: ÷ Dilates
ÿ Administer bronchi tree
bronchodilator for maximum
 as ordered by ventilation
the physician
(salbutamol)
ÿ Nebulize ÷ To dilute
patient secretions
      
  
  
 
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Independent:
Subjective: Ineffective airway After 2 hrs of ÿ Monitor Vital ÷ For baseline Goal Met
³nahihirapan clearance related nursing signs data, needed After 2 hrs of
akong huminga, at to increased intervention, the especially for ongoing nursing
parang punong mucous patient will have body comparison intervention, the
puno ng plema production patent effective temperature ÷ To provide patient had
ang dibdib ko´ as secondary to airway clearance ÿ Position the maximum effective airway
verbalized by the infection as as evidenced by client on lung clearance as
patient manifested by RR decrease in RR semi-fowler¶s expansion evidenced by
of 28, tachypnea, from 28 down to position decrease in RR
and presence of 20 ÿ Instruct deep ÷ To promote from 28 down to
Objective: crackles upon breathing deep 18
÷ Tachypnea auscultation exercises inspiration
÷ RR 28 ÿ Instruct ÷ To expel
÷ Use of coughing secretions
accessory exercises
muscles ÿ Increase oral ÷ To dilute
÷ Crackles fluid intake secretions
present upon ÿ Teach SO on ÷ To aid the
auscultation of performing patient move
the chest CPT and expel
÷ Presence of secretions
sticky sputum
Dependent: ÷ Dilates
ÿ Administer bronchi tree
bronchodilator for maximum
 as ordered by ventilation
the physician
(salbutamol)
ÿ Administer ÷ To treat the
antibiotic underlying
(cefuroxime) cause
as ordered by
the physician