c
c


 
  Y    
 c

Y  c


   

  Ineffective Accumulated fluid After 8 hrs of c

c
c! Goal Met.
͞Nahihirapan Airway in the alveoli & nursing Y After 2 hrs of
siyang huminga͟, Clearance r/t airways interferes intervention, the ) Auscultated *Y Auscultation of nursing
as verbalized by exudates in with ventilation of client will breath sounds q 2 crackles may indicate intervention,
the mother of the alveoli. & gas exchange demonstrate Hours. pulmonary the client
patient. within the alveoli. good respiration congestion . demonstrated
 (MSN .3RD Ed. beyond the range (MSN . Vol.2. 7th Ed good
  Lemone, Priscilla, & of 30-60 rpm. p.1666.) respiration
-nasal flaring Karen beyond the
noted Burke.p.887.2004) *Y An OЇ saturation of rangeof 30-60
-Lying flat on bed less than 90% rpm.
-RR of 65 2) Monitor blood (normal 95% to
breaths/min gas value and 100%) or a partial
- with pulse rate pulse oxygen pressure of OЇ of less
of 159 bpm saturation levels as than 80 (normal 80 to
- with BP of available. 100) indicates
100/60 significant
- with crackles oxygenation
upon lung problems (Grap,
auscultation 2002; Berry &
noted Pinnard, 2002).
-with oxygenation
therapy via nasal
cannula at 3-5 *Y ´ithout exercise of
Lpm prn. the calf and leg
 3) Assisted the muscles, blood pools
client in ROM in the veins of the
exercises as lower extremities.
indicated and This stagnant blood
ordered flow may allow clot
to develop. ´ith
time, these clots can
break loose and
 become emboli,
eventually lodging in
the small vessels of
the pulmonary
vascular system.
Blood flow and gas
exchange in the lungs
is then impaired
(Fundamentals of
Nursing, K
ozier.p.1344).

*Y Clears airway &

facilitates oxygen
4) Instructed client delivery. (Ibid)
in effective
coughing, deep
breathing

*Y An upright position
Y allows for maximal
Y 5) Position the lung expansion;
client to optimize lying flat on bed
respiration, head causes abdominal
of bed 45 degrees organs to shift
q 2°. toward the chest,
which crowds the
 lungs and makes it
 more difficult to
 breathe. Studies
 have shown that in a
 mechanically
 ventilated client,
 there is a decreased
 incidence of
 pneumonia if the
 client is positioned
 at a 45- degree
 semi-recumbent
 position as opposed
 to a supine position
 (Collard et al 2003;
 Drakulovic et al,
 1999).





c
c! *Y ?  Y
 YY

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(3-5 Lpm), YY  Y
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Bronchodilators
decrease airway
2)Administer resistance
medication secondary to
bronchodilators bronchoconstrictors.
and inhaled (Drug Handbook)
steroids as
ordered.
Salbutamol q 2
hours.
c"
Y
CUES NURSING rationale PLAN NURSING RATIONALE EVALUATION
DIAGNIOSIS INTERVENTION

S: ͞Sobrang init ng Altered body Pyrexia results from a After 2 hoursof 1)Monitored vital 1)Establish baseline Goal met, patient͛s
anak ko͟, as temperature: response to bacterial nursing intervention, sign especially data for temperature
verbalized by the Fever related to or viral infection, as a patient will manifest temperature. subsequent decreased from 38.2
patient͛s mother. tissue injury defense mechanism a decrease in evaluation and to to 37.3°C
secondary to of our body. temperature in the monitor clients at
O: inflammation of (Fundamentals of range of 38.2 C- risk for imbalanced
alveolar tissues nursing) 37.5°C. temperature such
-Temperature: 38.2 as clients at risk for
°C diagnosis of
infection.
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touch #
$Y%&
$YY
The set of the point '()
Y
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appearance thermostat changes 2)Rendered tepid 2)Reduce a client͛s
suddenly from the sponge bath (TSB). fever by promoting
-flushy face normal value as a heat loss through
result of the effects conduction.
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soles noted Y #
$Y%&
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(Fundamentals of Y '*(
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Nursing, Barbara
kozier, pp.428) 3)Provided cold 3)Helps promote
compress on head.Y body cooling.
Y ( +
Y

Y #
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Y
Y
4)encouraged 4)To meet
increased fluid intake increased
metabolic demands
and prevents
dehydration.
 (" YY
 #
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 '*(
Y
5)loosened tight 5)allows the body
clothing to dissipitate heat
 through radiation
 (lbid.)


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c
c! analgesia by
blocking pain
impulses by
Administer inhibiting synthesis
paracetamol as of prostaglandin in
ordered (paracetamol the CNS or of other
500 mg 1 tab PRN for substances that
T ш 37.8 ºC) sensitize pain
receptors to
stimulation. The
drug may relive
fever through
central action in
the hypothalamic
heat-regulating
center.
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matagal akong to dyspnea 
  Y shift, the patient patterns of sleep in 
Y6 YY decrease in sleep
makatulog (3-4   YYY will report a good normal YY pattern
hours lang halos  Y Y sleep without environment: !
disturbance & had
minsan ang tulog Y  interruption ( sleep amount, bedtime slept comfortably
ko),͟ as verbalized Y
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by the pt.
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aids, & interfering
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Y
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grimaces orientation as day 
 Y
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 Y
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 YY
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rest Y

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