GENERAL DATA

 
Name :
Age : 1 month old
Sex : Male
Birthday : 07 - 02 - 10
Birthplace : Aborlan , Palawan
Address : Aborlan , Palawan
Name of Mother :
  Name of Father :
 Nationality : Filipino
 Religion : Catholic
 Chief Complaints : Difficulty of
Breathing
 Admitting Impressions : Pneumonia

 Date and time of admission : 8 - 30 -

10 / 4 : 00pm
 Attending Physician : Dra . Celzo

PATHOPHYSIOLOGY
 NURSING CARE PLAN
ASSESSMENT NURSING PLANNING
Subjective Cue:
none
DIAGNOSIS
Ineffective airway clearance R/T STG: @ the end of 1 hour nursing
obstructive tracheobronchial secretions. intervention, patient should be able to cough
Objective Cues: out phlegm at least 10cc.
Non-productive cough

Restlessness noted

irritable Definition: Inability to clear secretions or

RR= 68cpm obstructions from the respiratory tract to
CR= 136bpm maintain a clear airway.
Wheezing sound noted on all lung fields

LTG: @ the end of 8 hours nursing

BACKGROUND KNOWLEDGE: intervention, patient should be able to
According to Virginia Henderson, the maintain airway patency , clear breath
unique function of the nurse is to assist the sounds, normal skin color.
individual, sick or well, in the performance .
of those activities contributing to health or
its recovery that he would perform unaided
if he has the necessary strength, will, or
knowledge. And to do this in such a way as
to help him gain independence as rapidly as
possible. It is the role of the nurse to take
care of the sick until he has fully recovered.
NURSING EVALUATION
INTERVENTION
Independent: He was not able to expectorate any
1. Assess rate/depth of respirations and chest movement.
R: Tachypnea, shallow respirations, and asymmetric chest tracheobronchial secretions.
movement are frequently present because of discomfort of moving  
chestwall.
2. Elevate head of bed.
Revisions :
R: Lowers diaphragm, promoting chest expansion, mobilization Repeat all the interventions done.
and expectoration of secretions.
3. Instruct and/or change patient’s position.
R: This will help to facilitate secretion movement.
4. Encourage increase in fluid intake.
R: To maintain hydration and aid in mobilization of sectetions.
5. Perform backclapping.
R: To help loosen secretion.
Dependent
6. Assist in nebulization.
R: Facilitates liquefaction and removal of secretions.
ASSESSMENT NURSING PLANNING
Subjective Cue:
None
DIAGNOSIS
Altered thermoregulatory R/T increased
metabolic rate secondary to health
STG: @ the end of 45minutes nursing
intervention, parent or significant others will
 condition. be able to demonstrate behaviors to maintain
 normal temperature.

Objective Cues: Definition: A state in which the individual’s

Restlessness noted body temperature is elevated above his or
Warm to touch her normal range. LTG: @ the end of 8 hoursd nursing
Flushed skin intervention, the patient will be able to
Dry lips maintain core temperature within normal
RR= 68cpm BACKGROUND KNOWLEDGE: range, 36.5 – 37.5 C.
CR= 136bpm According to Martha Roger’s definition of
temp= 38.2 C nursing, a humanistic science dedicated to
compassionate concern with maintaining
and promoting health, preventing illness and
caring for and rehabilitating the sick. It is
therefore the role of the nurse, in this case,
to assist the patient so he can immediately
recover.
NURSING EVALUATION
INTERVENTION
1. Monitor patient temperature (degree and pattern); note shaking =The patient’s latest temperature
Independent:

chills/profuse diaphoresis.
R: To have a basis for evaluation. Fever pattern may aid in 37.1
diagnosis, and chills often precede temperature spikes.
2. Monitor environmental temperature; limit/add bed linens as
indicated.
R: Room temperature/number of blankets should be altered to
maintain near-normal body temperature.
3. Provide tepid sponge baths.
R: May help reduce fever.
4. Increase fluid intake.
-encourage the mother to continue breatfeeding
R: To prevent dehydration.
5. Provide health teachings on the signs and symptoms of
hyperthermia, interventions, and the need for prompt intervention.
R: To promote wellness.
.


 THE END!!!....THANK YOU...