Assessment

Explanation of the Problem S> Hindi na siya The problem started masyadong ubo ng upon entry of ubo. Streptococcus O> with productive pneumonia, coughing episodes noted Haemophilus influenza > with nasal secretions and Staphylococcus noted species Mycoplasma > with wheezing noted at the lower lung fields pneumonia, Legionella upon auscultation and Chlamydia Species > respiratory rate of 38 through inspiration cpm, regular or aspiration. There is > with symmetrical activation of defense chest expansion mechanism. Then, there > no retractions noted is loss of effectiveness of > no chest indrawing noted defense mechanism. A> Ineffective airway Penetration of the sterile clearance related to lower respiratory tract retained secretions (lungs) happens and to secondary to PCAP the alveoli, then there is multiplication of invasive cells. Thus, irritation of the airways occurs, increasing goblet cell production, and mucus. Cough is present as a mechanism to expel the secretions.

Objectives LTO> After 3 days of nursing interventions, the patient will maintain patent airway as manifested by clear breath sounds, normal rate of respiration (20-40 cpm) STO> After 8 hours of nursing Interventions, the patient: 1. will manifest stable and normal vital signs (RR, PR, Temp) 2. will manifest clear breath sounds as manifested by absence of wheezes 3. will adhere and comply to all therapeutic regimens like medications

Nursing Interventions

Rationale

Evaluation > Goal partially met since the cough and colds of the patient is still present but it was alleviated in some ways.

> Assess for respiratory rate >Provides a basis for evaluating adequacy of ventilation > Note chest >Use of accessory movement; use of accessory muscles of respiration muscles during respiration may occur in response to ineffective ventilation >Auscultate breath sounds; > Crackles/wheezes note areas with presence of indicate accumulation of adventitious sounds secretions and inability to clear airways >Elevate patients back >Positioning helps maximize lung expansion and prevent > Do backtapping orthopnea > The reason for this to to break up the mucus in the lungs in order to make it easier for the > Keep patients back dry patient to cough them up. > Instruct to increase > To promote comfort patients fluid intake and adequate ventilation >To help liquefy > Encourage mother to feed secretions patient with vitamin C-rich food >To boost immune system to prevent further infections