Patient: Cadangdang, 2 years old

Admitted on August 25, 2018

Diagnosis: PCAP C

Date/Time Assessment Needs Nursing Diagnosis Objectives of Care Intervention Evaluation

August 28, Subjective: C Ineffective Airway After 4 hours of 1. Maintain patient’s GOAL MET
2018 “Nagkalisod og O clearance r/t the nursing airway patent.
hinga ning bata G excessive fluid and interventions, ® Mucus surrounding After 4 hours of
8:00 am kay puno man gud N mucus in the The patient will be the airway passages nursing
ni ug plema iyang I respiratory passages able to: could interfere with interventions, the
7am-3pm baga” as T breathing. patient was able
shift verbalized by the I R: Irritation of the 2. Perform nasotracheal to breathe
father. V respiratory system  maintain suctioning as normally without
E causes both airway as necessary, especially if chest indrawing
- inflammation of the evidenced by cough is ineffective. and have a
Objective: P air passages and a having a ® Suctioning is needed respiratory rate
 Copius, E notable increase in respiratory when patients are within normal
thick and R mucus secretion. As rate within unable to cough out limits: 32 breaths
clear C mucus production normal range secretions properly due per minute.
mucus E increases, the  show no to weakness, thick
secretions P airway clearance is signs of mucus plugs, or
 Bilateral T compromised. respiratory excessive or tenacious
crackles U distress mucus production.
A 3. Position the patient
Vital signs: L upright if tolerated.
T: 36.5 C Regularly check the
HR: 110 P patient’s position to
RR: 50 A prevent sliding down in
T bed.
T ® Upright position
E limits abdominal
R contents from pushing
N upward and inhibiting
lung expansion. This
position promotes
 better lung expansion
and improved air
exchange.
4. Note for changes in
HR, RR, and
temperature.
®Increased work of
breathing can lead to
tachycardia. Retained
secretions or atelectasis
may be a sign of an
existing infection or
inflammatory process
manifested by a fever
or increased
temperature.
5. Instruct the client to
increase oral fluid
intake
® Increased fluid
intake can reduce the
viscosity of mucus
6. Educate the father on
the characteristics of
the patient’s possible
respiratory status
change.
7. ® Early recognition of
the onset of respiratory
difficulties could mean
early detection of
distress.
8. Provide postural
drainage, percussion,
and vibration as
ordered.
 ®Chest physical
therapy helps mobilize
bronchial secretions; it
should be used only
when prescribed
because it can cause
harm if patient has
underlying conditions
such as cardiac disease
or increased
intracranial pressure.
9. Administer salbutamol
via nebule as ordered
by physician
®Salbutamol relaxes
the muscles in the walls
of the small air
passages in the lungs.
This helps to open up
the airways and helps
to relieve chest
tightness, wheezing,
and cough.
10. Educate father on how
to use the nebulizer
®If the father is
educated on tools used
on his daughter he feels
better equipped.