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8/3/2019 ncp-sampoli

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Nursing Care Plan

1st PrioritySampoli,Jannelle Karen

(Pneumonia)Assessment Planning Intervention/Rationale Evaluation

Subjective: Short Term: Independent: Short Term:

"Nahihirapang After 4 hours of Monitor Respirations & After 4 hours of huminga ang anak nursing breathe sounds (e.g. nursing interventionko" as verbalized intervention the tachypnea, crackles, the patient was ableby the mother. patient maintain wheezes. maintain airway

airway patency. patency. Goals met.Objective: To maintain adequate

Long Term: patent airway. Long Term:Restlessness

After 1 day of Observe for signs of After 1 day of Pale color nursing respiratory distress nursing intervention

intervention the (increased rate, the mother of theRR= 63 cpm mother of the baby restlessness/anxiety use baby has

demonstrate of accessory muscle for demonstratedAdventitious behaviours to breathing. behaviours tobreath sounds improve or improve or maintain(crackles, wheezes maintain clear To assess changes. Note clear airway. Goalssounds) airway. complication. met.

Nursing Position headDiagnosis appropriate for age and

condition.Ineffective AirwayClearance may be to open or maintainrelated to open airway in at rest or decreased lung compromised individual.expansion (fluid &air accumulation), Dependent:pain inflammatoryprocess, possibly Administer Analgesics.evidenced bydyspnea, To improve cough whentachypnea, cough pain is inhibiting effort.and ABG's.

Give expectorants &bronchodillators asordered.


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To mobilize secretions.

Collaborative:

Monitor/document serialchest x-ray, ABG's, pulseoxymetry reading.

To assess changes, notecomplications.

Assist with procedures(e.g. bronchoscopy,tracheostomy).

To clear/maintain openairway.


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2nd Priority

Impaired gas exchange

Assessment Planning Intervention/Rationale Evaluation

Subjective: Short Term: Independent: Goals partially metas evidence by:

"Napansin kong After 15 minutes of Assess patient'snamumutla ang nursing respiratory rateanak ko" as intervention theverbalized by the patient will be able This will serve asmother to have a respiratory function

respiratory rate

Objective with-in normal Monitor vital signs,range note for changes inPale, cardiac rate

Long Term:Nasal flaring, Hypoxia is associated

After 30 minutes of with signs of increased Dyspnea with a nursing breathing effort respiratory rate of intervention the63 cpm, patient will be able Oxygen saturation

to maintain aTackycardia with a normal breathing To determine oxygenpulse rate of 158 pattern of 30-60 sufficiencybpm cpm

Elevate head orNursing position the patientDiagnosis appropriately

Impaired gas To facilitate airwayexchange related efficiencyto alveolar capillarychanges as Maintain adequatemanifested by intake and outputabnormal skincolor For mobilization of

secretions

Collaborative

Recommend themother to stimulate the


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baby to cry once in awhile

To enhance lungexpansion and tomaximize oxygenation

Dependent:

Sunctioning as ordered

To maintain airwayProvide supplementaloxygen at the lowest concentration asordered/to increaseinhalation of oxygenconcentration

Nebulizer as ordered

For bronco dilation


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3rd Priority

Acute Pain

Assessment Planning Intervention/Rationale EvaluationSubjective: Short Term: Independent: Short Term:

"Umiiyak siya pag After 15 minutes of Determine cause of After 15 minutes of nadidiinan ko ang nursing pain nursingtiyan nya" as intervention, the intervention, theverbalized by the mother of the to access precipitating mother was able tomother of the patient will be able contributory factors demonstrate use

patient. to demonstrate use of relaxation skillsof relaxation skills Ask mother to identify and diversionalFace scale: 7/10 and diversional behaviours that may activities to reduce

activities to reduce indicate pain pain of the patient.Objective: pain of the patient. Goals met.

since the client isirritability Long Term: unable to verbalize Long Term:

feelings.crying After 1 hour of After 1 hour of

nursing Instruct the mother on nursingabdominal intervention, the use of relaxation intervention, thetenderness patient will be able technique such as patient is still

to demonstrate back rub irritable and cryingcool fingertips/toes actions that pain is because

reduced from 7/10- to ease pain. medication cannotRR: 63 cpm 3/10. be given stat duePR: 158 bpm Collaborative: to interval of last

dose administeredNursing Coordinate with the Goals met.Diagnosis: mother on proper way

of positioning of theAcute pain related patient.to exessive use of accessory muscle of Familiarity of thebreathing and patient with the mother abdominal colic as will facilitatemanifested by cooperationirritability andcrying Dependent:


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Administer analgesicsas ordered

To relieve pain thru proper medication

4th Priority

HyperthermiaAssessment Planning Intervention/Rationale Evaluation

Subjective: Short Term: Independent: Short Term:

"Mainit sya pag After 1 hour of Note chronological and After 1 hour of hinahawakan ko" nursing developmental age of nursingas verbvalized by intervention the client intervention thethe mother patient will be able patient was able to

to maintain core Children are more maintain core

Objective: temperature within susceptible to heart temperature withinnormal range. stroke. normal range.Increase in body Goals met.temperature above Long Term: Monitore corethe normal range temperature. Long Term:

After 4 hours of Warm to touch nursing To evaluate degree of After 4 hours of

intervention the hyperthermia nursingV/S as follows: patient will be able intervention thePR: 180 to demonstrate Tepid Sponge Bath the patient was able toRR: 58 free of patient demonstrate freeTEMP: 38.5 complications such of complications

as neurological To decrease body such asNursing damage. temperature thru the neurologicalDiagnosis: principle of heat damage. Goals

transfer via conduction metHyperthermia and evaporationrelated to bodytemperature Collaborative:elevated abovenormal range Educate mother of

patient on proper wayof performing spongebath.For mother to be ableto do the procedure

properly at home incases medicationscannot be provided at immediately


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Report to the NODsignificant increase intemperature

For NOD to assess if administration of anti- pyretic is possible

Dependent:

Administer antipyretics,orally/rectally asordered.

To assist with measureto reduce bodytemperature.

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