NURSING CARE PLAN

Name: Sarsalejo, Dylan Jay Montero Date of Admission: september 16 ,2018

Age: 9 months old Room Number: 1015 A

Impression: Received Patient lying on bed, asleep with ongoing IVF #3 Hospital Number: 000000000079563
D5LR @ 55cc/hr
Attending Physician: Dr. Sandra Revela
Diagnosis: Pediatric community acquired pneumonia C
Student Nurse’s Name: Antonio Luis Enrique Lu

Signature:
Assessment: Chief Complaint: Came in due to labor pain
Breathing: Labored
Lung sound: wheezing History of Present Illness:
Circulation: regular
Skin: warm, dry A case of D.J.M.S. 9 months old, male, Roman Catholic residing at Youngs Compound,
Neuro: alert pagsabungan mandaue city cebu, was admitted due to long-term cough and cold.
Abdomen: unremakable Patient’s mother decided to go to University of cebu Medical center to have him checked
Eye: spontaneous by the Physician and was advised for admission.
Bowel sound: present
Past Health History Relevant to Present Illness:

Patient D.J.M.S has no history of hospitalization

Significant Findings

CBC: Normal range:

V/S During Admission:
RBC: 4.15 x10^12L 4.5-6.0 x10^12L low
Hemoglobin: 108 g/L 140-180 g/L low BP: - HR/PR: 116 bpm
Hematorcrit: 0.33 0.40-0.52 Temperature: 36.6 c RR: 57 cpm
X- ray section
Impression:
Pneumonia, both lungs

Vital Signs (during first contact with the patient)

8am 10am 12pm 2pm

T 36.6 36.7 36.8 36.8

P 116 124 110 146

R 57 64 60 68

02 100% 100% 100% 99%

NCP 1
Cues/ Evidences Nursing Diagnosis Scientific Basis Outcome Criteria Nursing Intervention Rationale Evaluation

Subjective: Ineffective airway Pneumonia is After 3 days of Independent: After 3 days of

clearance related to anexcess of fluid in nursing care patient ● Monitor and ● This is to nursing care patient
“Kusog iyang presence of secretions thelungs resulting will be able to: record vital establish was able to:
ginhawa” as from aninflammatory signs baseline data
verbalized by the process.The ● Improve and reference have improved
patent’s mother inflammation respirations ● Assist the ● This is to respirations and
istriggered by ● Have no signs patient to mobilize difficulty of breathing
manyinfectious of breathing change secretions was slightly not
Objective: organismsand by difficulty position every noted; repositioned in
inhalation of irritating ● Able to 30 minutes moderate high back
● Productive agents.Infectious expectorate ● This is to rest but the patient is
cough with pneumoniasare secretions and ● Position maintain a not able to
 phlegm categorized ● Maintain a patient in patent airway expectorate phlegm
● Exertional ascommunity patent airway moderate high ● To ascertain
Effort Upon acquired(CAP) or back rest status and Goal Partially Met
expectoration hospitalacquired ● Auscultate note progress
● Crackles (nosocomial)dependi breath sounds
heard upon ng on wherethe and air
auscultation patient wasexposed to movement ● Strict
● Nasal flaring infectiousagent ● Administer compliance of
noted medications medications
● Rapid as prescribed will lessen the
breathing chances of
noted complications
● To remove
● Perform nasal nasal
suctioning secretions

Source: Doenges, M. et al Nurse’s Pocket Guide: Diagnosis, Prioritized Interventions, and Rationales: Philadelphia: F.A. Davis Company

Cues/ Evidences Nursing Diagnosis Scientific Basis Outcome Criteria Nursing Intervention Rationale Evaluation

Subjective: Hyperthermia related Infection causes a After 8 hours of INDEPENDENT: After 8 hours of
to infection rise in body nursing care the nursing care the
“Ni taas iyang temperature, it also patient’s temperature ● Provide tepid ● Enhances patient was able to:
temperature” As acts as an antigen will lower down to sponge bath. heat loss by
verbalized by the triggering immune normal levels evaporation ● Maintain
patient’s mother. system responses. & conduction normal range
The hypothalamus ● Reduces of
reacts to raise the set ● Promote bed body heat ● Be free of
Objective: point and the body rest production. dehydration
respond by ● Maintain
 ● Temperature producing heat. ● Assist patient ● Increases vital signs at
of 39.5°C in changing comfort normal levels
(Hyperthermi into dry
a clothing
● Respiration ● Monitor vital ● Notes
of 68 cpm signs progress &
(tachypnea) changes of
DEPENDENT: condition
● Maintain IV ● Prevents
fluids as dehydration
ordered by
physician. ● Reduces
● Administer fever.
Paracetamol
as ordered

COLLABORATIVE
: ● Ensures
● Discuss continuous
condition of intervention
the patient
with other
members of
the health
care team

Source: Doenges, M. et al Nurse’s Pocket Guide: Diagnosis, Prioritized Interventions, and Rationales: Philadelphia: F.A. Davis Company
Cues/ Evidences Nursing Diagnosis Scientific Basis Outcome Criteria Nursing Intervention Rationale Evaluation

Objective: Risk for aspiration Aspiration After 8 hours of INDEPENDENT: After 8 hours of
● Displayed pneumonia is a nursing care patient nursing care patient
Irritability complication of will be able to ● Encourage to ● provide quick was able to
● Nasal pulmonary demonstrate no burp after and demonstrate no
Congestion aspiration. incidence of breastfeed accessible evidence of
● Coughing Pulmonary aspiration aspiration means of aspiration
during is when you inhale suctioning if
breastfeed food, stomach acid, ● Instruct necessary
or saliva into your patient’s ● To prevent
lungs. You can also mother to from choking GOAL IS MET.
aspirate food that elevate
travels back up from patient’s head
your stomach to your during
esophagus. breastfeeding
● Perform
All of these things suction as ● To clear
may carry bacteria needed secretions
that affect your
lungs. Healthy lungs ● Auscultate ● To check for
can clear up on their lung sound any signs of
own. If they don’t, wheezes and
pneumonia can silent
develop as a ● Monitor aspiration
complication Respiratory ● Early
rate recognition of
breathing
problems may
prevent
complications
.