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    Roseben R. Somido: PATIENT: Delos Reyes, Lloyd: 2mos - Old CASE: Pneumonia Severe

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    Roseben Somido
    -Administer medications as ordered. -Monitor VS and lung sounds every hour. -Provide comfort measures and position changes every 2 hours. -Encourage fluid intake.

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    Roseben R. Somido: PATIENT: Delos Reyes, Lloyd: 2mos - Old CASE: Pneumonia Severe

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    Roseben Somido
    12 views2 pages
    -Administer medications as ordered. -Monitor VS and lung sounds every hour. -Provide comfort measures and position changes every 2 hours. -Encourage fluid intake.

    Original Title

    Airway Clearance, Ineffective

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    -Administer medications as ordered. -Monitor VS and lung sounds every hour. -Provide comfort measures and position changes every 2 hours. -Encourage fluid intake.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    12 views2 pages

    Roseben R. Somido: PATIENT: Delos Reyes, Lloyd: 2mos - Old CASE: Pneumonia Severe

    Uploaded by

    Roseben Somido
    -Administer medications as ordered. -Monitor VS and lung sounds every hour. -Provide comfort measures and position changes every 2 hours. -Encourage fluid intake.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    ROSEBEN R.

    SOMIDO
    PATIENT: delos Reyes, Lloyd: 2mos.old CASE: Pneumonia Severe ASESSMENT DIAGNOSIS INFERENCE EXPECTED OUTCOME NSG. INTERVENTION Independent: -Monitor VS every 1 hour and auscultate the lungs to note for any changes. -Elevate the head And change position every 2 hours. -increase fluid intake. RATIONALE EVALUATION After 12 hours of nursing intervention the patient was able to: -have respiratory rate from 58cpm to a normal range of 35-40cpm. -Maintain airway patency. -fluid aids in the mobilization and expectoration of secretions. -to be able to report immediately to the physician and do appropriate emergency intervention. -Demonstrate reduction of congestion with breath sounds clear. -Be able to readily expectorate and clear secretions. -Mother will verbalize understanding of

    Subjective: Inuubo-ubo siya atsaka parang nanghihina as verbalized by the mother. Objective: ineffective cough Auscultated crackles breath sound Fatigue Tachypnea VS taken as follows: RR: 58 cpm

    Ineffective airway clearance related to respiratory secretions as manifested by auscultated crackles, tachypnea and cough

    Entry of After 12 hours of microorganism in nursing the nasal passages intervention the patient will: Invasion of the respiratory system -have respiratory rate from 58cpm to a normal range of 35-40cpm. -Maintain airway patency. -Demonstrate reduction of congestion with breath sounds clear. -Be able to readily expectorate and clear secretions. -Mother will verbalize understanding of

    Provides as a baseline data and to be able to identify complications. -to promote lung expansion.

    Activation of immune response (mucus production resulting to cough)

    Ineffective immune response related to overwhelming infection

    -Observe signs of respiratory distress and signs and symptoms of infection.

    Invading lung parenchyma

    the causes and therapeutic regimen for the illness.

    Release of endotoxins and exotoxins

    -provide health teaching to the mother regarding The cause and therapeutic regimen for the disease. Collaborative: Administer analgesics and expectorants and Bronchodilators as ordered by the physician.

    -So the mother will have knowledge in the appropriate care for the illness.

    the causes and therapeutic regimen for the illness.

    Continous mucus production

    To improve cough effort as well as to minimize the secretions.

    Massive inflammation (pneumonia) resulting to ineffective airway clearance

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