I.

NCP

Patient: R.C.S.B. Age: 1 yr, 1 mo. Sex: female Hospital No: 060000086199

CUES NURSING BACKGROUND PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE INTERVENTIONS

S> Nahihirapan yata Ineffective Bacterial After 8 hours of > Monitor > With secretions in the After 8 ours of
syang huminga saka Airway microorganism Nursing respiratory patterns, airway, the respiratory Nursing Intervention,
lagi na lang sumusuka Clearance enter the airways Intervention, the including rate, depth, rate will increase the Pts breathing had
and effort. no more adventitious
ng plema, as related to Pts breathing
verbalized by the Pts inability to Inflammation of will have no sounds
> Assist with > It is preferable for the (crackles/gargles)
grandmother. maintain clear the lung/s more clearing secretions client to cough up
airway as adventitious present when
from pharynx by secretions. Gentle
O> (+) sputum characterized Air sacs filled sounds present auscultated
offering tissues and suctioning of the
with pus & other
production by (+) sputum, (crackles/gargles) gentle suction of the posterior pharynx may
liquids
Rapid, shallow (+) crackles, when auscultated oral pharynx if stimulate coughing and

breathing rapid & shallow necessary help remove secretions
Presence of
(+) crackles, breathing obstructions in the
gargles > Chest physical
airways
therapy helps mobilize

> Provide postural bronchial secretions
Inability to drainage, percussion,
breathe properly and vibration as
ordered > Bronchodilators
decrease airway
> Administer resistance secondary to
medications such as bronchoconstriction
bronchodilators or
inhaled steroids as
ordered.
 Patient: R.C.S.B. Age: 1 yr, 1 mo. Sex: female Hospital No: 060000086199

CUES NURSING BACKGROUND PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE INTERVENTIONS

S> May lagnat po Altered body Bacterial After 2 hours of > Monitor Pts > To determine if the After 2 hrs of Nursing
yata ang anak ko, temperature microorganisms Nursing temperature q1 hr Pts temperature is intervention, the Pts
as verbalized by the related to bacterial (e.g. pulmonary Intervention, the above the normal body temperature had
Pts mother. invasion in the pathogens) enter Pts temperature temperature decreased from 39.8 C
lungs as the airway will decrease to 37.4 C
manifested by from 39.8 C to > Allows the patient to
O> febrile body temperature These normal range > Encourage Pt to recuperate physical After 2 hrs of Nursing
moist skin higher than bacteria/viruses (36.6 - 37.5 C) rest strength Intervention, the Pts
tachypnea, RR= normal, tachypnea, infects the lung/s skin has cooled off a bit
33 cpm (+) crackles After 2 hours of > To maintain
(+) crackles Inflammation of the Nursing hydration status and
lung/s Intervention, the > Encourage Pt to increased fluid intake
Pts skin will increase fluid intake helps lessen febrility
Signs and cool off
symptoms of > Sponge bath with
Age: Pneumonia warm water evaporates
1 yr.1 mo. (e.g.temperature off his skin, thus,
may be greater than > Encourage the Pts cooling off the Pt
37.5C), tachypnea, guardian to do tepid
coughs with sponge bath > Promotes return of
greenish secretions body temperature to
normal

> Administer
antipyretic
medications as
prescribed
 CUES NURSING BACKGROUND PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE INTERVENTIONS

S> Ayaw nyang Imbalanced Bacteria or virus After 4 hours of > Assess for recent > The consequences After 4 hours of Nursing
kumain, yung gatas Nutrition due to attacks the lung/s Nursing changes in of malnutrition can Intervention, the Pt
sinusuka lang naman frequent vomiting Intervention, the physiological status lead to a further started taking foods
nya, and and not eating the weakened immune Pt will start taking that may interfere decline in the which he usually eat
Mas payat sya ngayon, usual foods taken systems foods which he with nutrition patient's condition (crackers)
dati ang lakas naman as manifested by usually eat (rice, that then becomes
kumain decreased weight, Pneumonia crackers, chicken self-perpetuating if After 4 hours of Nursing
as verbalized by the Pts food aversion, and breast,etc) not recognized and Intervention, the Pt didnt
grandmother. weakness. Symptoms of treated. vomit anymore the
Pneumonia: After 4 hours of ingested milk
O> vomits ingested nausea or Nursing > Often toddlers will
milk vomiting, may Intervention, the > Provide eat more food if other
Food aversion experience Pt will not vomit companionship at people are present at
Decreased wt profound anymore the mealtime to mealtimes.
weakness weakness w/c lasts ingested milk encourage
for a long time. nutritional intake > Protein-calorie
malnutrition most
> Determine often accompanies a
healthy body disease process
weight for age and
height > Cases of vitamin D
deficiency have been
> Assess client's reported among dark-
ability to obtain skinned toddlers who
and use essential were exclusively
nutrients. breast fed and were
not given
supplemental vitamin
D.