EPIGLOTTITIS

ASSESSMENT NURSING SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS EXPLANATIO INTERVENTION
N
SUBJECTIVE Ineffective Entry of pathogen SHORT INDEPENDENT: INDEPENDENT: GOAL MET.
CUES: TERM 1. Assess vital signs 1. To know if the SHORT TERM
Airway Damage the cell especially the patient is
“Antaas ng lagnat OUTCOME: OUTCOME:
ng apo ko”
Clearance membrane of the epi respiratory rate, experiencing
After 4 hours of After 4 hours of
“dalawang araw na related to glottis effort, pattern, and severe respiratory
nursing nursing intervention,
siyang nilalagnat ng depth. distress.
thick Pathogen filtered in
intervention, the
2. Assess the arterial 2. Increase ABGS
the patient increased
mataas” patient will intake of oxygen as
“nahihirapan don
secretions the epiglottis Blood Gases may indicate
increase intake verbalized of the
sya huminga dahi; secondary to 3. Auscultate the lungs pulmonary
of oxygen. patient that she is
masakit daw yung Start of inflammation 4. Position the patient secretions and
infection as process LONG TERM in a sitting position respiratory
not have trouble of
lalamunan niya at breathing.
evidenced by OUTCOME: while leaning fatigue.
hirap siyang
Inflammation of After 3 days of forward position 3. To know the lung
kumain” as presence of
sounds because LONG
epiglottis nursing with mouth open TERM
verbalized by the bright red
father of child.
interventions, and tongue out. stridor is late OUTCOME:
throat with Blocks the airway the patient will 5. Monitor the intake ominous sign of After 3 days of
OBJECTIVE have clear
edema and and output of the epiglottitis that nursing
CUES: Ineffective airway airway by patient. means emergency interventions, the
- 5 years old muffled clearance absence of 6. Provide tepid sponge airway patient have clear
- T – 38.4 °C cough inflammation. bath management. airway as evidenced
PR – 75 bpm DEPENDENT: 4. For improved by absence of
RR- 25 1. Administer IV oxygen. inflammation and
breath/min Reference: antibiotics as 5. To know if the bright red throat.
- Febrile Maternal and Child 8th ordered by the patient is
- Skin is warm to edition volume 2 page doctor. dehydrated.
touch with 1110 – 1112 by COLLABORATIVE: 6. To decrease body
flushing PIlliterri 1. Administer temperation
- Patient looks humified oxygen DEPENDENT:
weak in 2. Prepare for 1. To kill the
appearance intubation or infection
- Sore throat harsh tracheostomy COLLABORATIVE:
voices 1. To moist the air
- Hoarseness oxygenation
- Difficulty of 2. Artificial airway
swallowing foods is required to
- Muffled cough promote oxygenation
- Throat is seen as and ventilation
a cherry-red
structure and
edematous