Assessment Medyo nahihirapan siyang huminga as verbalized by the patient s SO O: >Rales noted upon auscultation >Ineffective cough >change

of facial color while coughing >nasal flaring noted >slightly pale in appearance >Vs as follows: Temp: 37.2 RR: 64 bpm PR: 150 bpm

Nursing Diagnosis Ineffective airway clearance related to ineffective cough with sputum production

Planning After the nursing intervention the patient will demonstrate reduce of congestion with breath sounds clear

Intervention Establish and maintain NPI

Rationale To facilitate rapport and gain the trust of the client This is an indicative of respiratory distress and accumulation of secretions To maintain open airway and to enhance ventilation to different lung segments To clear airway when excessive or viscous secretions are blocking airway These may compromise airway

Monitor respiration and breath sounds

Evaluation After the nursing intervention the patient demonstrated reduction of congestion as evidenced by clear breath sounds

Elevate the head

Perform suctions as needed

Monitor or feeding intolerance and abdominal distention Keep environment allergen free Give bronchodilators as ordered Increase fluid intake by breastfeeding

This will prevent the exacerbation of the condition This will help improve respirations Hydration can help liquefy and expel secretions

Assessment Hindi niya mailabas yung plema niya as verbalized by the client s SO O: >persistent cough noted >rales noted upon auscultation >difficulty of breathing >change of facial color while coughing >nasal flaring noted >slightly pale in appearance

Nursing Diagnosis Impaired gas exchange related to collection and retention of secretions

Planning After the nursing intervention, the client will demonstrate improve ventilation

Intervention Establish and maintain NPI

Rationale To facilitate rapport and gain the trust of the client To have a baseline data To monitor accumulation of secretions To maintain airway

Evaluation After the nursing intervention, the client demonstrated improve ventilation

Monitor vital signs and cardiac rhythm Auscultate breath sounds

Elevate head of bed and position the client appropriately Encourage frequent position changes

Promotes optimal chest expansion and drainage of secretions To increase level of O2 in blood and tissue To mobilize secretions Helps limit o2 needs and consumption To treat underlying conditions

Provide supplemental oxygen as prescribed

Maintain adequate input and output Promote a calm and restful environment Administer medications as indicated

Assessment Titingnan pa daw kung mataas pa ang bacteria sa katawan niya as verbalized by the patient s SO O: >slight increase in body temperature >presence of adventitious sounds in both lung fields >productive cough >skin pale in color >v/s as follows: Temp: 37.5 PR: 153 RR: 64

Nursing Diagnosis Risk for infection related to the stasis of secretions

Planning

After the nursing intervention, the patients SO will identify interventions to reduce risk of infection

Intervention Frequently assess and monitor the patient s condition

Rationale Note signs and symptoms of sepsis

Monitor client s visitors for respiratory illnesses Maintain sterile technique in suctioning Instruct the S.O concerning about the disposition of secretions and report changes in color, amount and odor of secretions.

To limit exposures, thus reducing crosscontamination

Evaluation After the nursing intervention, the patient s SO identified interventions to reduce risk of infection

To prevent bacterial contamination

To promote safety disposal of secretions and to assess for the resolution of pneumonia or development of secondary infection. To reduce spread or acquisition of infection. To enhance fast recovery and regain strength

Encourage good hand washing techniques.

Encourage adequate rest

A good nutritional intake can strengthen body immune defense

Stress the importance of breastfeeding Encourage the mother to keep an eye to the baby and observe anything that the baby is putting in his mouth . Administer antimicrobials as ordered. To prevent entry of microbes.

To combat microbial pneumonias