Date/Time Assessment Needs Nursing Diagnosis Objective of Intervention Evaluation

Care
December 13, Patient: Sump A Ineffective airway After 8 hours of 1. Auscultate the lungs for presence of GOAL
2019 Age: 2yrs old C clearance related to nursing normal or adventitious breath sounds PARTIALLY MET
T copious sputum interventions,
10:00 am I production the patient will R- Diminished lung sounds or the presence of After 8 hours of
Objective V be able to: adventitious sounds indicates an obstructed nursing
7am-3pm shift -(+) crackles at I Ineffective airway airway and the need for suctioning interventions, the
right and left lower T clearance occurs when an 1. Maintain patient was able to
lung fields Y artificial airway is used patent airway as 2. Assess the rate and depth of respirations
-(+) wheezing because normal evidenced by and chest movement. - Expectorate
heard on posterior E mucociliary transport clear breath R – Tachypnea, shallow respirations, and sputum
chest during X mechanisms are bypassed sounds, decrease asymmetric chest movement are frequently - Decrease
exhalation E and impaired. in respiratory present because of discomfort of moving chest respiratory rate
-(+) ineffective R rate from 40 to wall and/or fluid in lung. from 42 to 37
productive cough C Irritation of the 35, and increase - O2 saturation
-Flaring nostrils I respiratory system causes in O2 saturation 3. Monitor V/S increased from
and use of S both inflammation of the from 88% to 88 to 95%
accessory muscle E air passages and a 95% R – The respiratory rate is the one commonly - (-) wheezing
when breathing notable increase in mucus assessed when using the IMCI booklet in heard
-Chest indrawing P secretion. Inflammation diagnosing pneumonia. A child that is 12 - (+) productive
noted A of the mucosa is months to 5 years is considered fast breathing cough still
-mucus on T responsible for sputum if the respiratory rate is 40 breaths per minute present
patient’s nose T production rather than or more. High fever is also common with - (+) soft
E other changes that occur bacterial pneumonia so monitoring crackles on
V/S R in diseased lung tissue temperature is also important right and left
T: 37 N (Jeffrey Maestrelli et al, lower lung
CR: 150 2001). 4. Instruct the mother to position patient semi- fields
RR: 44 fowlers and change the patient’s position
O2saturation: 85 Expectorated sputum frequently
to 91% contains lower
respiratory tract R- Semi-fowlers position lowers the
secretions, as well as diaphragm and promotes effective chest
secretions from the nose, expansion, aeration of lung segments, and
mouth and pharynx, and mobilization of secretion
cellular debris and micro-
organisms (Rubin, 2002). 5. Encourage mother to continue
breastfeeding on demand with strict aspiration
precaution

R – Lukewarm liquids such as that of

breastmilk help in softening secretions and aid
in expectoration of secretions. Breastmilk also
replenishes loss of fluids during pneumonia
infection
6. Monitor body temperature as indicated

R – Increase in body temperature also

increases metabolic demand and oxygen
consumption of the cells, in return this
increases respiration of patient. Monitoring
for fever which is common in bacterial
pneumonia is important

7. Administer adequate fluid intake via IV as

indicated by physician

R – Maintaining hydration increases ciliary

action to remove secretions and reduces a
viscosity of secretions.

8. Maintain bed rest

R- Allowing the patient to rest decreases

emotional and physical exhaustion and
reduces oxygen demands

9. Administer medications as prescribed by

the physician

R – Certain medications such as mucolytics

and bronchodilators help in reducing
bronchospasm and mobilization of secretions.

10. Administer supplemental O2 as prescribed

by physician

R –. Because of increase mucus secretion,

oxygen could not adequately enter the lung
and alveoli where gas exchange occur. Since
the body only acquires 20% of oxygen from
room air, administering O2 supply, increases
the percentage of oxygen given to the body.