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1 Ineffective Airway Clearance

Mucus is produced at all times by the membranes lining the air passages. When the membranes are irritated or inflamed, excess mucus is
produced and it will retain in tracheobronchial tree. The inflammation and increased in secretions block the airways making it difficult for the
person to maintain a patent airway. In order to expel excessive secretions, cough reflex will be stimulated. An increased in RR will also be
expected as a compensatory mechanism of the body due to obstructed airways.

Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Expected Outcome

Ineffective airway SHORT TERM: > Monitor and record vital > To obtain baseline SHORT TERM:
S>(none) clearance r/t signs data
accumulation of After 3-4 hours of After 3-4 hours of NI,
O> tracheobronchial > Assess patient’s > To know the
NI, pt.’s SO will be pt. shall have
secretions condition. patient’s general
able to demonstrate demonstrated improve
>Restlessness condition
improve airway > Elevate head of bed and airway clearance AEB
with nasal
clearance AEB encourage frequent > To promote reduction of congestion
flaring
reduction of position changes. maximal inspiration, with breath sounds clear
> With rales on congestion with enhance and RR improve
both lung fields breath sounds clear > Keep back dry and expectoration of
LONG TERM:
and RR improve loosen clothing secretions in order to
> warm, flushed
skin LONG TERM: >Auscultate breath sounds improve ventilation After 2-3 days of NI, pt.
and assess air movement shall have established
>minimal > To promote
After 2-3 days of and maintained airway
comfort and
colorless nasal NI, pt. will be able >Monitor child for feeding patency.
secretions to establish and intolerance and abdominal adequate ventilation

maintain airway distention


>tachypnea > To ascertain status
patency. and to note progress
AEB > Instruct the SO to

RR=53bpm provide an increased fluid


> To avoid
intake for the child
>DOB compromising the
> Instruct the SO to airway
>tachycardia provide
> To help liquefy the
>irritability adequate rest periods for secretions

>chest the child


> Rest will prevent
indrawing > Give expectorants and fatigue and decrease

>cough bronchodilators as ordered. oxygen demands for


metabolic demands
>cyanosis > Administer oxygen
therapy and other > To further
>noisy breathing medications as ordered. mobilize secretions

>pallor > To clear airway


when secretions are
>changes in RR
blocking the airway
and rhythm
indicated to increase
>risk for
oxygen saturation.
infection
>orthopnea

>tachypnea

2 Impaired Gas Exchange


The exchange in oxygenation and carbon dioxide gases is impeded due to the obstruction caused by the accumulation of bronchial secretions in
the alveoli. Oxygen cannot diffuse easily.

Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Expected Outcome

Impaired gas SHORT TERM: > Monitor and record vital > To obtain baseline SHORT TERM:
S>O exchange related to signs data
inflammation of After 6 hours of NI, pt Patient shall
O> Pt airways and > Observe color of skin, > Cyanosis of nail
will be able to demonstrate
accumulation of mucous membranes and nail beds may represent
manifested: sputum affecting demonstrate improvement improvement in gas
O2 and CO2 beds, noting presence of vasoconstriction or the
in gas exchange AEB a exchange AEB a
>Restlessness transport peripheral cyanosis. body’s response to
decrease in respiratory rate decrease in respiratory
>with nasal fever/ chills
to normal > Elevate head of bed and rate to normal
flaring
encourage frequent position > To promote maximal
LONG TERM: LONG TERM:
> With rales on changes. inspiration, enhance
both lung fields After 1-2 days of NI, pt expectoration of Patient shall
>Keep back dry.
will be able to secretions in order to demonstrate improved
Patient may
demonstrate > Promote improve ventilation ventilation and
manifest:
adequate oxygenation
improved ventilation and adequate rest periods >To avoid coughing
> Metabolic of tissues AEB
adequate oxygenation of
acidosis > Rest will prevent absence of symptoms
tissues AEB absence of >Change position q 2 hrs.
> Circum-oral fatigue and decrease
symptoms of respiratory of respiratory distress.
> Keep environment allergen
cyanosis oxygen demands for
distress.
free
metabolic demands
>DOB
> Suction secretions PRN
>To promote drainage
>tachypnea
>Instruct SO to increase fluid of secretions
intake of the child
> To reduce irritant

> Administer oxygen therapy effects on airways


as ordered.
> To clear airway
when secretions are
blocking the airway

indicated to increase
oxygen saturation

>To liquefy secretions

> O2 therapy is
indicated to increase
oxygen saturation
3 Hyperthermia
A person experiences hyperthermia due to the inflammatory process wherein the body tries to compensate and adapt to the dse. condition. As a
defense mechanism, the body produces host inflammatory cells causing fever. Interluekin-1 function as a pyrogens that acts on the
hypothalamus. 1L-1 act as a hormone where it is carried by the inflammation site of production to the CNS, where it acts directly on the
hypothalamic thermal control center, thus elevating the thermal set point.

Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Expected Outcome

Hyperthermia Short-term: > Assess pt’s condition and >To have baseline Short-term:
S>Ø monitored vital signs. data.
After 3 hours of nursing After 3 hours of
O> The pt >Perform tepid sponge bath >To promote heat loss
interventions the pt’s nursing interventions
manifested by evaporation and
temperature will be >Instruct the SO to provide the pt’s temperature
conduction.
decrease to normal limits an increase fluid intake for shall have decreased
>Increase body
from 37.9 to 37.5ºC the child. >To support to normal limits from
temp. at 37.9ºC
circulating volume 37.9 to 37.5ºC
Long-term: >Maintain patent airway and
>Skin is warm to and tissue perfusion.
provide blanket for the child. Long-term:
touch. After 3 days of nursing
>To promote pt’s
interventions the pt will be >Maintain bed rest and After 3 days of
>With flushed safety and to avoid
able to maintain a temp. adequate rest periods. nursing interventions
skin. chills.
within normal range . the pt shall be able to
>Increase in RR >Ask SO to provide high
>To reduce metabolic maintain a temp.
caloric diet for the child within normal range .
The patient may demands/ Oxygen

manifest: >Administer antipyretics as consumption.


ordered.
>chills >To meet increase
metabolic demands.
>lack of appetite
>To lower the
temperature.

4 Disturbed Sleeping Pattern


Sleep is disrupted when a person experiences unpleasant sensation arising from difficulty of breathing and ineffective expectoration of mucus
secretions in the airways.

Nursing
Assessment Planning Nursing Interventions Rationale Expected Outcome
Diagnosis

Disturbed Sleep Short Term: -monitor vital signs -to have a comparable Short Term:
S > The mother Pattern r/t baseline data
verbalized that difficulty of After 3 hours of nursing -encourage SO to increase After 3 hours of
her child often breathing -to promote
wakes up during interventions the SO will intake of warm milk for the nursing interventions
midnight. drowsiness
be able to verbalize child the SO shall have
understanding of sleep -to promote comfort verbalized
O> patient - provide a quiet environment
disturbance and identify and relaxation /sleep understanding of sleep
manifested: for the child
interventions to promote periods for the child disturbance and
>changes in sleep for the child. -instruct SO to provide a dim identified
behavior Long Term: environment for the child -to promote comfort interventions to
(irritability) for the child promote sleep for the
After 3 days of nursing >advise SO to provide
child.
>restless interventions, SO will be blanket for the child >to avoid chills and to
able to report promote comfort Long Term:
>DOB >instruct SO to elevate HOB
improvement in sleep
> to maximize lung After 3 days of
>nasal flaring pattern of the child.
expansion of the child nursing interventions,
The patient may and to decrease DOB the SO shall have
manifest: reported improvement
in sleep pattern for the
>lack of interest
child
in food

>weight loss

>DOB

>tachypnea

5 Risk for Infection


Immuno-suppression due to decrease in hemoglobin, leukopenia, and suppress inflammatory response gives a greater opportunity for
pathogenic bacteria to invade and inoculate in a specific body part of a susceptible human body. Thus, leading to a further damage or infection.

Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Expected Outcome

Risk for infection (spread) Short term: 1. Monitor v/s closely, 1. To know potential Short term:
S>  related to inadequate especially during initiation fatal complication
secondary After 6 hours of nursing of therapy. that may occur. The patient’s S.O
O>the patient defenses(decrease interventions the patient’s shall have verbalized
hemoglobin, hematocrit 2. Instruct the S.O 2. To promote safety
manifested and immunosuppression) S.O will verbalize her her understanding of
concerning about the disposal of secretions
understanding of individual
>fever of 38.3ºC disposition of secretions and and to assess for the
individual causative/risk causative/risk factors
report changes in color, resolution of
>presence of factors and demonstrate and demonstrate
amount and odor of pneumonia or
adventitious lifestyle changes to lifestyle changes to
secretions. development of
sounds in both prevent further infection. prevent further
secondary infection.
lung field. 3. Encourage the SO to infection.
Long term:
perform good hand washing 3. To reduce spread
>productive Long term:
After 1-2 days of nursing techniques. or acquisition of
cough
interventions the patient infection. The patient shall have
4. Encourage adequate rest.
>skin pale in will be free from possible been free from
4. To enhance fast
color spread of infection. 5. Stress the importance of possible spread of
recovery and regain
increasing the child’s infection.
>restlessness strength.
nutritional intake.

The patient 5. A good nutritional


6. Encourage the mother to
may manifest: intake can strengthen
keep an eye to the baby and
body immune
>activity observe anything that the
defense.
intolerance baby is putting in his mouth.
6. To prevent entry of
>fever 7. Ask SO to provide a good microbes.
hygiene for the child. (bed
>cough and 7. To eliminate MO
bath)
colds
8. To prevent GI
8. Ask SO to provide an
>pallor disturbance
adequate safe drinking
>cyanosis milk/water for the child 9. To avoid chills and
to prevent the child
>DOB 9. Ask SO to keep the child
from having fever
warm and to provide blanket
>tachypnea
10. To combat
10. Administer
>tachycardia microbial
antimicrobials as ordered.
pneumonias.

6 Risk for Imbalanced Nutrition


A disruption in the mucosal barrier causes gastric acid to come into contact with gastric tissues and damage them causing irritation or
inflammation. This leads to alteration of the mucosal barrier impairing the absorption process with in the stomach and putting the patient at
high risk for imbalance nutrition less than body requirements.

Nursing
Assessment Planning Nursing Interventions Rationale Expected Outcome
Diagnosis

S= The mother Risk for SHORT TERM: -Monitor vital signs - To have baseline SHORT TERM:
verbalized an imbalanced data
After 3 hours of Nursing - assess for difficulty of The SO shall have
evident weight nutrition, less than
Interventions, the SO will swallowing and the ability to - can be factors that verbalized
loss in her child. body requirement
be able to verbalize swallow can affect ingestion
related to decrease understanding of
O= Patient understanding of causative and causative of
nutrient absorption - encourage family members causative factors
manifested: factors when known and altered nutrition
to prepare food of patient’s when known and
necessary interventions for
>pallor preferences - to maintain adequate necessary
the child.
caloric intake interventions for the
>lack of appetite - develop meal plan with the
LONG TERM: child.
patient - to meet the
>lack of interest
After 2 days of Nursing nutritional needs of LONG TERM:
to food offered - ask the SO to join the child
Interventions, the patient the client
during meal time The client shall have
>type of food will be able to
- to enhance intake demonstrated
cannot meet the demonstrate behaviors,
behaviors, lifestyle
metabolic lifestyle changes to regain
changes to regain
demand of the and/or maintain
and/or maintain
child (powder appropriate weight.
appropriate weight.
milk, milo, chips)

The patient may


manifest:

>constipation

>diarrhea
>weight loss

>pallor