NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Ineffective airway After 8 hours of INDEPENDENT: At the end of 8 hours

clearance related to nursing intervention of nursing intervention
"Giubo siya ug increased phlegm patient will be able Provided comfortable  To compensate the the patient was able to
maglisod siyag ginhawa productions to: positioning by lack of sleep and demonstrate cough
tungod sa iyang plema  Demonstrate ease adjusting bed prevents fall from with decreased sputum,
tapos mura man ning in coughing as providing a little slipping to the floor. adequate rest,
lala" as verbalized by showed by normal elevation and has  Helps to minimize comfortable
the patient's mother. breath sounds locked the side rails. mucosal drying and positioning and was
(gone are the rale Help changes the facilitate easy calm, seldom cries,
OBJECTIVE: sounds), and patient's clothing to elimination of relieved restlessness;
change of comfortable loose secretions improved totality of
 Constant crying respiratory cycle to cloth  Changing of wellbeing.
 Poor coughing reflex normal cycle of Provided therapeutic sleeping position
 Continuous coughing breathing less 60 touch by rubbing the promotes better lung
with cackle or rale cpm. back especially during expansion and
sounds  Relieve respiratory coughing. improved air
 Lethargic distress by the time Instructed significant exchange
 Rapid breathing medical other to suck the nasal  Those drugs given
 Sweating intervention are airway of the infant promote clearance
 Vital signs taken: introduced DEPENDENT: of airway secretions
Temperature: 38.2oC  Maintain airway Have provided and may reduce
Heart Rate: 164 bpm patency of the medication as airway resistance.
Respiratory Rate: 106 infant by providing prescribed Cefuroxime  Helps mobilize
cpm steam inhalation or (200mg) bronchial secretions
suctioning nares Every 8 hours, and provides
obstruction with intravenously comfort to the
bulb syringe patient.

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 sASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Elevated body After 8 hours of Independent At the end of 8 hours

temperature nursing intervention of nursing intervention
“Init kayo akoang anak related to ongoing patient will be able  Provided Tepid  Helps lower down the patient was able to,
dayon dili kaayo infections of alveoli to: Sponge Bath. the Temperature. achieve normal breath
daghan ang ma-ihi  Show signs of sounds, reduced body
niya” as verbalized by relieve discomfort  Provided health  Infants are temperature,
the patient’s mother. such as minimize education about especially respiratory rate and
crying. removal of excess sensitive to over heart rate were normal,
 Reduce body clothing and bundling as they show signs of relived
OBJECTIVE: temperature at changing upon are unable to discomfort such as
 Profuse sweating normal range 0f profuse sweating regulate temp. minimize crying. And
 Flushed skin between 36.5 – Often when infants display signs of
 Teary eyes 37.5 oC. are ill, parents will improved wellbeing
 Warm to touch  Decrease bundle them up, such as skin is no
 Vigorous crying respiratory rate but don’t realize longer warm to touch
 Vital signs taken: and Heart rate at they are making and skin color is back
Temperature- 38.2oC normal range. things worse. to normal.
Heart Rate-164bpm  Display sufficient  Discussed  To promote
Respiratory Rate-106 sleep of average importance of wellness.
cpm four times for breastfeeding to SO  Oral fluid intake in
three hours during and encouraged to the form of
day time. increase breastfeeding will
 Display signs of breastfeeding by help infants
improve expressing small strengthen their
wellbeing such as amounts of milk immunizations
skin is no longer into babys’ mouth.  Decreases warmth
warm to touch  Bed side care. and increases
and skin is no evaporative
longer flushed cooling.

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 showing an
elevated  Monitored vital  Vital signs provide
temperature. signs and rechecked accurate indication
of core
DEPENDENT: temperature.

 Acetaminophen  These drugs

(paracetamol) inhibit the
80mg, every 4 prostaglandin that
hours via serve as mediators
intravenous of pain and fever.
Reduces fever by
acting directly on
the hypothalamic
heat- regulating
center to cause
vasodilation and
sweating, which
helps dissipate
heat.

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 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Ineffective airway After 8 hours of INDEPENDENT: After 8 hours of

clearance related to nursing interventions  Rechecked  Indicative of nursing interventions
“Sigeg tulo ang sip-on accumulation of the patient will: respirations and respiratory distress the patient was able
sa akong anak, excessive mucus in  Demonstrate breathe sounds, noting and accumulation to:
maglisod siyag the nose noiseless rate and sounds. of secretions.  Demonstrate
ginhawa unya sigeg respirations with effortless breathing.
hilak” as verbalized clear breath sounds  Provided well  To promote patent  Achieve relaxed
by the patient’s  Maintain airway ventilated room. of obstructed positioning
mother. patency by airway.  Respirations
suctioning nares decreased from
OBJECTIVE: obstruction with  Elevated head with  To prevent 106cpm to 46cpm
bulb syringe pillows vomiting with  Minimized vigorous
 Runny nose  Provide aspiration into crying
 Nasal flaring comfortable  Have demonstrated to lungs.  Release suffering.
 Frontal and positions of semi- the significant other  To provide comfort  Lessen weak
maxillary appears fowler for infant the appropriate responses.
flushed on face with small pillows position for the infant
 Vigorous crying  Minimize vigorous for better nasal
 Appears weak crying breathing
 Distressed  Respirations will
 Sweating decrease from Encouraged  To help building up
 V/S taken: 106cpm to 46cpm significant other to immune system.
Temp.- 38.2°C  Relieve distress breastfeed the patient.
HR- 164bpm  Alleviate weak Instructed significant  To restore
RR- 106cpm responses other to increase skin wholeness and
to skin contact wellbeing at the
physical and
emotions of the
baby.

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 DEPENDENT:

 Administered  To mobilized
Albuterol secretions.
Sulfate(Salbutamol)
2.5ml every 8 hours in
intravenous site as
prescribed by the
doctor

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