Nursing Care Plan

Patient’s Name: G. S. Age: 5 y/o

Impression Medical Diagnosis: Pediatric Community Acquired Pneumonia considered in the Retrocardiac Area (Pulmonary Hypoinflation)
Nursing Diagnosis: Ineffective Airway Clearance r/t retained mucus secretions secondary to Pediatric Community Acquired Pneumonia-C as evidenced by

EXPLANATION OF IMPLEMENTATION CRITERIA FOR

ASSESSMENT THE PROBLEM OBJECTIVE EVALUATION EVALUATION

INTERVENTIONS RATIONALE

S: “Sometimes, I ➢ Ineffective STO: Diagnostic STO: STO:

can't breathe when Airway Within 8 hours of Interventions: Fully met if: Partially met
sleeping there's Clearance: effective nursing 1. Monitor and 1. To assess the Within 8 hours of patient was able to
something blocking Reduced ability Intervention the record vital signs. patient's overall effective nursing meet 2/4 of the
my nose and I wake to clear patient will be able condition, which Intervention the criteria:
up” secretions or to: can indicate the patient will be able ➢ Demonstrated
obstructions from ➢ Effectively severity of the to meet 4/4 of the partial comfort
O: the respiratory clear infection and the criteria: and relaxation
➢ White-Yellowish tract to maintain secretions effectiveness of ➢ Effectively in breathing
sputum a clear airway ➢ Demonstrate treatment. cleared especially
➢ Series of ➢ PCAP, or improved 2. Assess rate and 2. To evaluate secretions. while sleeping.
purulent Pneumonia, in a comfort and depth of respiratory effort ➢ Demonstrated ➢ Showed
coughing 5-year-old occurs relaxation in respirations and and identify signs improved diminished lung
➢ Disturbance when a breathing chest of respiratory comfort and sounds.
when sleeping pathogen, such especially movement. distress relaxation in
due to as bacteria or a while sleeping. breathing
obstruction in virus, invades the ➢ Show improved 3. Auscultate for 3.To detect especially LTO:
airway lungs. This lung sounds presence of abnormal lung while sleeping. Partially met:
➢ With Presence invasion triggers ➢ Actively crackles sounds, such as ➢ Showed After 2-3 days of
of Crackles in an immune participate in crackles, which improved lung effective Nursing
left lung response, actions, such indicate fluid in sounds Intervention the
➢ Increased leading to as deep the lungs. ➢ Actively patient was able to
Respiratory Rate inflammation. breathing participated in meet 2/3 of the
➢ V/S taken as The inflammatory exercises. Therapeutic actions, such criteria:
follows: process causes Interventions: as deep ➢ Displays
BP: 90/60 the air sacs -Independent: breathing minimal
 mmHg (alveoli) in the LTO: 1. Encouraged for 1.To help thin exercises. presence of
Temp: 37.2° C lungs to fill with After 2-3 days of an increase of secretions and purulent
RR: 33 cpm fluid and pus, effective Nursing fluid intake. facilitate their Partially met if: coughing.
PR: 123 bpm hindering oxygen Intervention the removal, as well Within 8 hours of ➢ Limited rest
SpO2: 96 % exchange. 1 The patient will be able as to prevent effective nursing at night with
increased mucus to: dehydration, Intervention the disturbance
Nursing Diagnosis: production and ➢ Display no which can worsen patient will be able from an
Ineffective Airway swelling of the presence of symptoms. to meet 2/4 of the obstruction
Clearance r/t airways further purulent 2. Encourage client 2. To improve lung criteria: of airway
retained mucus obstruct airflow. 2 coughing. in deep breath expansion, ➢ Partially
secretions Additionally, the ➢ Maintain exercises. mobilize cleared
secondary to body's response Patent Airway secretions, and secretions.
Pediatric to infection can ➢ Maintain enhance ➢ Demonstrated
Community weaken the enough rest at oxygenation. partial comfort
Acquired cough reflex, night without -Dependent: and relaxation
Pneumonia-C as making it difficult disturbance 1.Administering 1.To treat the in breathing
evidenced by for the child to from an prescribed underlying especially
purulent coughing expel the excess obstruction of antibiotics and bacterial infection while sleeping.
and presence of mucus. This airway decongestants. and relieve ➢ Showed
crackles in left lung. combination of congestion, diminished lung
factors results in respectively. sounds.
ineffective Educative ➢ Moderately
airway Interventions: participated in
clearance, 1. Educate the 1.To prevent the actions, such
leading to family on the spread of as deep
symptoms like importance of infection to breathing
purulent hand hygiene to others, especially
coughing fever, prevent the within the family. Not met if:
and increased spread of Within 8 hours of
respiratory rate. infection. effective nursing
Intervention the
2. Emphasize the 2.To monitor the patient will be able
importance of child's progress, to meet 0/4 of the
follow-up assess the criteria:
appointments to effectiveness of ➢ Presence of
monitor the treatment, and purulent
child's progress identify any secretions.
and ensure potential ➢ No
complete complications. demonstrated
recovery. comfort and
relaxation in
breathing
especially
while sleeping.
➢ No indications
of improved
lung sounds.
➢ Did not
participat in
actions, such
as deep
breathing

LTO:
Fully met if:
After 2-3 days of
effective Nursing
Intervention the
patient will be able
to meet 3/3 of the
criteria:
➢ Displays no
presence of
purulent
coughing.
➢ Maintained
Patent Airway
➢ Maintained
enough rest at
night without
 disturbance
from an
obstruction of
airway

Partially met if:

After 2-3 days of
effective Nursing
Intervention the
patient will be able
to meet 2/3 of the
criteria:
➢ Displays
minimal
presence of
purulent
coughing.
➢ Partial Patent
Airway
➢ Limited rest at
night with
disturbance
from an
obstruction of
airway
Not met if:
After 2-3 days of
effective Nursing
Intervention the
patient will be able
to meet 0/3 of the
criteria:
➢ Presence of
purulent
coughing.
 ➢ Not patent
Airway
➢ No rest at night
with
disturbance
from an
obstruction of
airway

References:
Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (2018). NANDA International, Inc. nursing diagnoses : definitions & classification 2018-2020 (11th ed.). Thieme.

Marieb, E. N., & Hoehn, K. (2019). Human anatomy & physiology (11th ed.). Pearson Education, Inc.

Muhammad. (2024, October 28). Pediatric Pneumonia: Practice Essentials, Background, Pathophysiology. Medscape.com; Medscape.

https://emedicine.medscape.com/article/967822-overview?form=fpf

Pneumonia - Symptoms and causes. (2024). Mayo Clinic;

https://www.mayoclinic.org/diseases-conditions/pneumonia/symptoms-causes/syc-20354204#:~:text=Pneumonia%20is%20an%20infection%20that,%2C

%20chills%2C%20and%20difficulty%20breathing.