VII.

NURSING CARE PLAN

Assessment Nursing Diagnosis Planning Nursing Intervention Evaluation
 Altered body Short term: Independent: After 30 mins on
Objective: temperature related - After 1 hour of - Administer antipyretics, effective nursing
- Warm to touch to bacterial infection nursing intervention orally or rectally as intervention the client
- Temp = 39℃ as manifested by the patient’s ordered. Refrain from use was able to maintain
- Increase RR = 39 fever, cold, increased temperature will of aspirin products in core temperature of
cpm respiratory rate of 39 decrease from 39 children (may cause Reye 37.0 C
cpm, warm to touch ℃ to 37.5℃. syndrome or liver
with a temperature of failure) or individuals with
39℃. Long term: a clotting disorder or
- After 4 hours of receiving anticoagulant
nursing intervention therapy.
the patient’s vital - Promote surface cooling
sign will return to by means of undressing
normal range with (heat loss by radiation);
temperature of 36.5- cool, tepid sponge bath or
37.5, respiratory of local ice packs, especially
12-20 cpm. in groin and axillae (areas
of high blood flow) .
- Demonstrate - Instruct parents in how to
behaviors to measure the child’s
monitor and tenperature, at what body
promote temeprature to give
normothermia. antipyretic medications,
and what symptoms to
- report to physician.
- Discuss importance of
adequate fluid intake at all
times and ways to improve
hydration status when ill to
prevent dehydration.

Collaborative:
- Monitor hematologic test
and other pertinent lab
records.
- Provide supplemental
oxygen to offset oxygen
demands and
consumption.
- Administer replacement
fluid s and electrolytes to
support circulation
volume and tissur
perfusion.
- Discuss condition of the
patient with others
members of the health care
team.
ASSESSMEN DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
T

SUBJECTIV Impaired gas After 8 hours INDEPENDENT: After 4 hours of

E DATA: exchange of nursing nursing
“Nahihirapan related to intervention the - Assess respiratory - Manifestation of interventions,
huminga ang collection of patient will be rate,depth and ease respiratory distress in the patient
anak ko dahil secretions able to: dependent on indicative of achieved timely
sa ubo” as affecting 1. Demonstrat degree of lung involvement resolution of
verbalized by oxygen e improved and underlying general current infection
the mother exchange ventilation and status. without
across alveolar adequate O2, - Monitor body complications.
OBJECTIVE membrane and absence of temperature
DATA: symptoms of - High fever greatly
-Dyspnea respiratory increases metabolic
distress. demands and oxygen
-tachycardia consumption and alters
2. Verbalize cellular oxygenation.
-V/S taken as understanding - Elevate head of
follow: of causative the bed and change
factors position frequently
T: 39 appropriate - Promotes expectoration,
R: 45 intervention. -Limit visitors as clearing of infection.
indicated

- Reduces likelihood of
- Institute isolation exposure to other
precaution. infectious pathogens.

- Isolation technique may

be desired to prevent
spread and protect client
- Suction as from other infectious
indicated prose.

- Stimulates cough or
- Assist with mechanically clears airway
nebulizer in patient who is unable to
treatments cough effectively.

- Monitor - Facilitates liquefaction

effectiveness of and removal of secretions
antimicrobial
therapy
- Signs of improvement in
conditions should occur
COLLABORATI within 24 - 48 hours.
VE:
- Administer
antimicrobials as - These drygs are used to
prescribed contact most of the
microbial pneumonias.
ASSESMEN DIAGNOSIS PLANNING INTERVENTIO RATIONALE EVALUATIO
T N N
SUBJECTIV Ineffective SHOR INDEPENDENT Short term
E DATA: airway TERM : goal:
clearance due GOAL: - To provide baseline GOAL
“May halak to sputum -Assess vital data PARTIALLY
pa siya at production - After 8 signs MET
may plema pa hours of -Use of accessory
rin pag ubo nursing muscle indicates an
niya” as intervention, - Assess abnormal increase in
verbalized by the client’s respiratory work of breathing.
the client’s airway will be movements and
father. free of use of accessory -chest physiotherapy
secretions as muscles. includes the techniques
OBJECTIV evidenced by of postural drainage and
E DATA: clear lung - Teach mother chest percussion to
sounds after chest mobilize secretions from Long term
-patient coughing. physiotherapy smaller airways that goal:
demonstrate cannot be eliminated by GOAL
persistent means of coughing or PARTIALLY
coughing LONG suctioning. MET
TERM
(+) crakles GOAL: - To loosen secretion

V/S - After 2 days

T: 36.2C of nursing
P: 120bpm intervention, - Facilitates liquefaction
R: 33cpm the client will and removal of
be able to secretions
have effective
airway - Encourage
clearance and hydration at least
no sputum 8 glasses of
productions water/day - To promote
with normal pharmacologic regimen
lung sounds - Assist with
nebulizer
treatments.
- Consultants may be
helpful in ensuring that
proper treatments are
DEPENDENT: met.

- Administer
medication such
as bronco dilators

COLLABORAT
ION:

- Refers to the
pulmonary
clinical nurse
specialist, home
health nurse, or
respiratory
therapist as
indicated