NURSING CARE PLAN

Date of assessment: September 13, 2009 Assessment SUBJECTIVE: Nahihirapan po akong huminga dahil sa ubo ko as verbalized by the patient OBJECTIVE: RR= 27cpm, with rapid and shallow respirations With productive whitish cough (+) crackles upon lung auscultation (+) dyspnea (+) tachypnea Uses accessory muscles in Diagnosis INFFECTIVE AIRWAY CLEARANCE r/t increased accumulation of secretions in the respiratory tract 2o to bacterial invasion Scientific Explanation Invasion of bacteria Planning Intervention Rationale For baseline assessment To determine the extent of intervention to be given To promote lung expansion Contributes to the overall comfort of the patient To prevent dehydration and to prevent viscosity of the sputum Evaluation Within the 8 hours shift of rendering effective nursing interventions, goal was met AEB: Decreased in RR from 27cpm to 20 cpm Decreased secretion of whitish sputum Minimal crackles heard upon lung auscultation Minimal signs of dyspnea Minimal use of accessory muscles in

Within the 8 INDEPENDENT: hours shift of Monitor the rendering vital signs effective nursing especially interventions, the RR Irritation in the the patient will Assess for respiratory tract manifest the effective following: coughing A decrease Increased mucus in RR from production 27cpm to 20 Position the cpm patient in Decrease semi-fowlers Accumulation of secretion of or side lying secretions in the whitish position respiratory tract sputum Provide a Minimal wellcrackles ventilated DOB due to heard upon environment obstruction lung by opening auscultation the windows Minimal signs Increase the Ineffective of dyspnea fluid intake airway clearance Minimal use of the patient of accessory

breathing (+) irritability (+) restlessness

muscles in breathing Decrease in restlessness and irritability

Encourage deepbreathing and coughing exercises Encourage consumption of foods rich in vit. C Encourage rest and sleep

To ensure proper expectoratio n of secretion To boost immune system To aid in faster recovery

breathing Decreased in restlessness and irritability

COLLABORATIVE : Give antibiotics as prescribed, Ceftriaxone 1gm q 12 hours ANST(-) Nebulization of Salbutamol 1neb q 6hours An IVF of D %NM 1L x 12hours

To aid in faster recovery as pharmacologi cal management

Date of assessment: September 13, 2009 Assessment SUBJECTIVE: mainit po ang pakiramdam ko as verbalized by the patient OBJECTIVE: T= 37.9oC, febrile Skin is warm to touch Red-flushed skin (+) diaphoresis (+) irritability (+) restlessness Diagnosis ALTERED BODY TEMPERATURE: HYPERTHERMIA r/t inflammatory response 2o to invasion of bacteria Scientific Explanation Planning Intervention INDEPENDENT: Monitor the body temperature every 15 min Perform TSB Rationale Evaluation

Within 30 Invasion of minutes of microorganism rendering effective nursing intervention, the WBC and patient will macrophage manifest the attack the following: microbes A decrease of temperature WBC and from 37.9 oC macrophage to 37.5 oC release pyrogens Decrease in (interleukin) warm sensation of the skin Anterior A decrease hypothalamus is in red-

Change the clothing into a lighter fabric Provide a wellventilated environment by opening the windows

Within 30 For baseline minutes of assessment rendering effective nursing Helps lower intervention, goal was met down body temperatur AEB: A decreased e by heat of loss temperature Provides from 37.9 oC body to 37.3 oC refreshment Decreased in and heat warm loss sensation of It allows air the skin to circulate A decreased within the in redroom thus flushed skin promoting

stimulated Hypothalamus secretes prostaglandin Raise of hypothalamic set point hyperthermia

flushed skin Minimal diaphoresis Decrease in restlessness and irritability

Increase the fluid intake of the patient Encourage consumption of foods rich in vit. C Encourage rest and sleep

body relaxation nd heat loss To prevent dehydration To boost immune system To aid in faster recovery To aid in faster recovery as pharmacolo gical manageme nt

Minimal diaphoresis Decreased in restlessness and irritability

COLLABORATIVE: Give antipyretics as prescribed, 1amp q 4 o TIV prn T= 37.8 o C An IVF of D %NM 1L x 12hours Give antibiotics as prescribed, Ceftriaxone 1gm q 12 hours ANST(-)

Date of assessment: September 13, 2009 Scientific Assessment Diagnosis Explanation SUBJECTIVE: ACUTE PAIN r/t masakit po ang dilation of blood Microbial ulo ko as vessels in the invasion verbalizes by the scalp 2o fever patient Inflammatory P-upon response change in position Q-sharp Fever R-radiating in the occipital area of the Dilation of blood head vessel in the S-5/10 where sclap

Planning Within 1-2 hours of rendering effective nursing intervention, the patient will manifest the following: Pain rated from 5/10 to 2/10 Minimal grimace Decrease

Intervention INDEPENDENT: Check the vital signs Divert the attention of the patient by talking with the patient and listening to music Increase the fluid intake of the patient

Rationale For baseline assessment To alleviate pain

Evaluation Within 1-2 hours of rendering effective nursing intervention, goal met AEB: Pain rated from 5/10 to 1/10 Minimal grimace Decreased guarding behavior

To prevent dehydration

in 0 as no pain and 10 as severe pain T-constant

Headache

OBJECTIVE: (+) headache (+) grimace With guarding behavior in the head (+) irritability (+) restlessness (+) diaphoresis T= 37.9 oC RR= 27cpm PR= 88bpm

guarding behavior Decrease restlessness Decrease irritability With minimal diaphoresis RR ranges to normal (1220) PR still ranges to normal (60100)

Provide a quiet and well ventilated environment Encourage verbalization of pain Encourage to eat vit. C rich foods Encourage rest and sleep

To increase the comfort of the patient To determine the pain scale To boost immune system To aid in faster recovery To aid In faster recovery as pharmacologi cal regimen

Decreased restlessness Decreased irritability With minimal diaphoresis RR ranges to normal (1220) PR still ranges to normal (60100)

COLLABORATIVE : Give antipyretics as prescribed, 1amp q 4 o TIV prn T= 37.8 o C An IVF of D %NM 1L x 12hours Give antibiotics as prescribed, Ceftriaxone 1gm q 12

hours ANST(-)