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Noting Unusualities, Especially The Signs of Respiratory Distress

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bellie017
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160 views5 pages

Noting Unusualities, Especially The Signs of Respiratory Distress

Uploaded by

bellie017
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Date Cues Need Nursing Diagnosis Objective of Care Nursing Interventions Evaluation

September OBJECTIVE: A Ineffective airway At the end of 8 hours 1. Monitor respirations GOAL MET

14, 2010  Respiratory C clearance related to shift, the patient will be and breath sounds. September 15,

rate of 56 T infection secondary able to maintain airway ® Monitoring helps in 2010 @ 6:00 am

@ 12:00 cycles per I to Bacterial patency as evidenced by noting unusualities, At the end of our

AM minute. V meningitis. within normal range especially the signs of 8 hour shift the

 Tachypnea I ® A state in which respiratory rate. respiratory distress. client was able to
11
7 SHIFT noted. T an individual is 2. Position the head of the maintain airway

 Adventitious Y unable to clear client appropriate for patency as

sounds & secretions or his age. evidenced by

heard upon E obstructions from ®To or maintain the respiratory rate

auscultation, X the respiratory tract airway in at-rest within normal

crackles on E to maintain airway individual. range, RR: 45

both lung R patency. 3. Encourage mother to cycles in one full

fields. C breastfeed the baby as minute.

 Restlessness I Gulanick, et. al. necessary, and make

noted. S Nursing Care Plans. the baby burp every


 Chest X-ray E after breastfeeding.

impression: ® These steps involve

Bronchopne P patient in own health

umonia A care.

 WBC: 11. T 4. Keep the environment

15 (high T allergen free (e.g.

level) E dust).

R ® Allergens like dust

N may contribute to the

worsening of the

client’s condition.

5. Administer medications

(antibiotic,

bronchodilators) as

ordered.

® Helps patient in

relieving symptoms
and alleviate client’s

condition.

6. Explain to the mother,

the possible side effects

of the drug to be given

to the client.

® Explaining the side

effects of the drugs will

help the significant

others to enhance their

knowledge about the

drugs.

7. Perform gentle back

tapping after

nebulization.

® Chest physiotherapy

will help the patient


loosen secretion after

administering the

medication.

8. Watch out for

unusualities.

® Observing for

unusualities may help

in noting and reporting

any adverse effects the

drug might cause.

9. Encourage rest and

sleep.

® Reduces the

instances of

fatigability. A growing

infant also needed 8-

10 hours of sleep as he
continues on his

growth and

development process.

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