ASSESSMENT

PLANNING

INTERVENTIONS

EVALUATION

Subjective: Inuubo ang anak ko, as patient mother verbalized. Objectives: clear nasal secretions productive cough nasal flaring wheezing sound upon auscultation use of accessory muscle in breathing RR of 45 BPM NURSING DIAGNOSIS Ineffective airway clearance related to thickened secretions into airway passage.

Short Term Goal Wholly Compensatory After 2 hrs. of nursing interventions patient will maintain adequate airway patency.

Focused on positioning the patient on moderate high back rest

Helps maximize lung expansion.

Patient condition maintained.

Focused on increase oral fluid intake or systematic hydration as appropriate.

To enhance liquefaction of pulmonary secretions and facilitates expectoration of mucus.

Facilitated a well ventilated environment.

To promote adequate sleep.

Facilitated bed rest.

To reduce oxygen demand.

Patient Name: Ramos Jhamika Age: 1 6/12 Diagnosis: CFC, BPN, CNS Infection

ASSESSMENT

PLANNING

INTERVENTIONS

EVALUATION

Objectives: On and off cough and colds WBC of 19.8 g/L

Long Term Goal Wholly Compensatory After 6 hrs. of nursing interventions patient will free from signs and symptoms of infections.

Focused on

To limit

limiting the visitors.

exposures, reduce cross contaminations.

Patient condition maintained.

Focused on emphasizing significant of good personal hygiene.

A first line defense against nosocomial infections.

NURSING DIAGNOSIS Risk for secondary infections.

Focused on cleaning the surroundings of IV insertion site.

To reduce cross contaminations.

Depend on administering antibiotics and vitamins.

This drugs are used to combat microbial pneumonias and to increase immune

resistance. Patient Name: Ramos Jhamika Age: 1 6/12 Diagnosis: CFC, BPN, CNS Infection