NURSING CARE PLAN

CUES Subjective: NURSING DIAGNOSIS Impaired gas exchange r/t collection of secretions affecting oxygen exchange across alveolar membrane SCIENTIFIC RATIONALE Pneumonia is an excess of fluid in the lungs resulting from an inflammatory process. The inflammation is triggered by many infectious organisms and by inhalation of irritating agents. Infectious pneumonias are categorized as community acquired(CAP) or hospital acquired (nosocomial) depending on where the patient was exposed to infectious agent. OBJECTIVES After 4 hours of nursing interventions, the patient will achieve timely resolution of current infection without complications. NURSING INTERVENTION -Assess respiratory rate, depth and ease RATIONALE -Manifestation of respiratory distress is dependent on indicative of the degree of lung involvement and underlying general status. -High fever greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation. -Promotes expectoration, clearing or infection -Reduces likelihood of exposure to other infectious pathogens -Stimulates cough or mechanically clears airway in patient who is unable to cough effectively. -Facilitates liquefaction and removal of secretions EVALUATION

Objective: -nasal flaring V/S: T- 36.8 P-125 R- 42

-Monitor body temperature

-Elevate head of the bed and change position frequently. -Limit visitors as indicated -Suction as indicated.

-Assist with nebulizer treatments

NURSING CARE PLAN

CUES Subjective: May naturo la geap ha ira irong. Gnsisinip.on la geap hea as verbalized by the mother. Objective: -nasal discharges(whitish) -nasal flaring V/S: T- 37.9 P- 149 R- 48 NURSING DIAGNOSIS Impaired breathing pattern related to presence of semi- thick nasal discharges SCIENTIFIC RATIONALE Presence of semi thick discharges | Obstruction to the nares | Impaired Breathing pattern OBJECTIVES After 2-4hours of nursing intervention the client will demonstrate enhance breathing pattern. NURSING INTERVENTION -assess RR and pattern RATIONALE - assessment provides information about childs ability to initiate and sustain an effective breathing pattern -To facilitate lung expansion -To decrease viscosity of the discharges -Contains vitamin C that boost the immune system -assistancehelps the newborn by clearing the airway and promoting oxygenation -deep breathing helps in normalizing of breathing pattern EVALUATION

-Place the client in semifowlers using pillows -Encourage to increase fluid intake -Advised to take citrus fruits -provide respiratory assistance as needed

-assist in deep breathing exercises