FAILURE TO THRIVE

(MARINDUQUE, JAMES ROD AND TRANSFIGURACION, SHIDY C.)

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Data: Ineffective airway After 72 hours of Independent: After 72 hours
“since discharge from a clearance related nursing  Position the child in  This will ensure the of nursing
previous hospitalization at to bronchospasms interventions the high fowlers position maximum lung interventions
as evidence by
4 months of age, the severe coughing patient will be able and encourage deep expansion will be more the patient was
infant has had multiple and wheezing to maintain clear, breathing. Elevate dispersed more able to maintain
episodes of coughing and open airways as head of the bed/ effectively, thereby clear, open
wheezing” as stated by evidence by change position every improving airway airways as
parents. normal breath 2 hours and prn. clearance. evidenced by
sounds, normal normal breath
Objective Data: rate and depth of  Monitor v/s signs  To evaluate degree of sounds, normal
 History of significant respirations. especially respiratory compromise rate and depth
failure to thrive. rate, note for of respirations.
 Acute respiratory respiratory distress
failure.  Monitor respirations  Indicatives of GOAL: MET
 Multiple episodes of and breath sounds, respiratory distress
coughing. noting rate and and/or accumulation of
 Severe sternal sounds secretions; abnormal
retractions, wheezing breath sounds can be
and decreased oral heard including
intake and activity. crackles and
 Respiratory Failure diminished breath
with altered mental sounds owing to fluid-
status. filled air spaces and
diminished lung
Vital Signs: volume.
 Evaluate skin color,  Lack of oxygen will
PR: 163 bpm temperature, capillary cause blue/cyanosis
RR: 45 cpm refill; observe central coloring to the lips,
T: 36.8˚C versus peripheral tongue, and fingers.
sPO2: 89-90% cyanosis. Cyanosis to the inside
WT: 4kg of the mouth is a
medical emergency
 Note for changes in
mental status.  Increasing lethargy,
confusion, restlessness,
and/or irritability can
be initial signs of
cerebral hypoxia.
Lethargy and
somnolence are late
signs.
 Note presence of  Unusual appearance of
sputum; evaluate its secretions may be a
quality, color, result of infection,
amount, odor, and bronchitis or other
consistency. condition. A discolored
sputum is a sign of
infection; an odor may
be present
 Evaluates client’s  To determine ability to
cough or gag reflex protect own airway
and swallowing ability
  Use pulse oximetry to  Oxygen saturation
monitor oxygen should be maintained
saturation; assess at 90% or greater.
arterial blood gases Alteration in ABGS may
(ABGs) result in increased
pulmonary secretions
and respiratory fatigue.

 Insert oral airway as  To maintain anatomic

needed position of tongue and
natural airway,
especially when
tongue/ laryngeal
edema or thick
secretions may block
airway
 Advice CPT to mother  Helps on secretion of
excessive mucus

Dependent:
 Give expectorants/  Aids in reduction of
bronchodilators as bronchospasm and
ordered. mobilization of
secretions.
 Increase fluid intake  Hydration can help
to at least 2-8 oz/day liquefy viscous
 within cardiac secretions and improve
tolerance secretion clearance.

 To clear airway when

 Suction naso/ excessive or viscous
tracheal/ oral prn secretions are blocking
airway or client is
unable to swallow or
cough effectively
 For emergency

 Administer oxygen as
prescribed by the
physician.

Collaborative:
 Refer the patient to  To mobilize secretions
respiratory therapist from smaller airways
for chest that cannot be
physiotherapy and eliminated by means of
nebulizer coughing or suctioning.
management as
indicated.