ROSEBEN R.

SOMIDO
PATIENT: delos Reyes, Lloyd: 2mos.old CASE: Pneumonia Severe ASESSMENT DIAGNOSIS INFERENCE EXPECTED OUTCOME NSG. INTERVENTION Independent: -Monitor VS every 1 hour and auscultate the lungs to note for any changes. -Elevate the head And change position every 2 hours. -increase fluid intake. RATIONALE EVALUATION After 12 hours of nursing intervention the patient was able to: -have respiratory rate from 58cpm to a normal range of 35-40cpm. -Maintain airway patency. -fluid aids in the mobilization and expectoration of secretions. -to be able to report immediately to the physician and do appropriate emergency intervention. -Demonstrate reduction of congestion with breath sounds clear. -Be able to readily expectorate and clear secretions. -Mother will verbalize understanding of

Subjective: Inuubo-ubo siya atsaka parang nanghihina as verbalized by the mother. Objective: ineffective cough Auscultated crackles breath sound Fatigue Tachypnea VS taken as follows: RR: 58 cpm

Ineffective airway clearance related to respiratory secretions as manifested by auscultated crackles, tachypnea and cough

Entry of After 12 hours of microorganism in nursing the nasal passages intervention the patient will: Invasion of the respiratory system -have respiratory rate from 58cpm to a normal range of 35-40cpm. -Maintain airway patency. -Demonstrate reduction of congestion with breath sounds clear. -Be able to readily expectorate and clear secretions. -Mother will verbalize understanding of

Provides as a baseline data and to be able to identify complications. -to promote lung expansion.

Activation of immune response (mucus production resulting to cough)

Ineffective immune response related to overwhelming infection

-Observe signs of respiratory distress and signs and symptoms of infection.

Invading lung parenchyma

the causes and therapeutic regimen for the illness.

Release of endotoxins and exotoxins

-provide health teaching to the mother regarding The cause and therapeutic regimen for the disease. Collaborative: Administer analgesics and expectorants and Bronchodilators as ordered by the physician.

-So the mother will have knowledge in the appropriate care for the illness.

the causes and therapeutic regimen for the illness.

Continous mucus production

To improve cough effort as well as to minimize the secretions.

Massive inflammation (pneumonia) resulting to ineffective airway clearance