Assessment Subjective: Nahihirapan huminga ang anak ko at inuubo. As verbalized by the mother of the patient.

Diagnosis Ineffective airway clearance related to increased mucous production as evidence by crackles upon auscultation.

Inference Bacterial microorganism enter the airways Inflammation of the lung/s

Planning After 12 hours of nursing intervention, the patients breathing will have no more adventitious sounds present (crackles/gargles) when auscultated.

Intervention Independent:  Monitor respiratory patterns, including rate, depth and effort.  Assist with clearing secretions, gentle suction of the oral pharynx if necessary.  Provide postural drainage and percussion. Dependent  Provide medications such as bronchodilators or inhaled steroids as ordered.

Rationale  With secretions in the airway, the respiratory rate will increase.

Evaluation After 12 hours of nursing intervention the patients breathing had no more adventitious sound (crackles/gargle) present when asucultated and the airway clearance are improved.

Objective : RR: 36bpm (+) crackles

Air sacs filled with pus and other liquids

 It is preferable client to cough up secretions. Gentle suctioning of the posterior pharynx may stimulate coughing and help remove secretions.  Chest physical therapy will help mobilize bronchial secretions.

Presence of obstructions in the airway

Inability to breath properly

 Bronchodilators decrease airway resistance secondary to bronchoconstrictio n.

Assessment Subjective: Nilalagnat ang anak ko. as verbalized by the mother of the patient.

Diagnosis Altered body temperature related to bacterial invasion in the lungs as manifested by warm skin and a temperature of 38.3.

Inference Bacterial microorganism enters the airway. These bacteria/viruses infect the lung/s Inflammation of the lung/s

Planning After 8 hours of nursing intervention, the patients temperature will decrease from 39.8 to normal range (36.637.5)

Intervention Independent:  Monitor patients temperature q1. 

Rationale Close monitoring, to determine the patients temperature.

Evaluation After 8 hours of nursing intervention, the patients temperature had decreased from 39.8 to 37.4.

 Encourage patient to rest.

 Allows the patient to recuperate strength.  To maintain hydration status and increase fluid intake help lessen febrility.  Sponge bath with warm water evaporates off his skin, thus, cooling off the pt.  Promotes return of the body temperature to normal.  To offset increased oxygen demands and consumption.  To support circulating volume and tissue perfusion.

 Encourage patient to increase fluid intake.  Encourage the guardian to tepid sponge bath. Dependent.  Provide antipyretic medications as prescribed.  Provide supplemental oxygen.  Administer replacement fluids and electrolytes.

Objective: Flushed, warm skin Fever of 38.3.

Signs and symptoms of pneumonia Temperature may be greater than 37.5 Tachypnea Cough with greenish secretions

Assessment Subjective: Parang hinihingal yung anak ko. as verbalized by the mother of the patient.

Diagnosis Ineffective breathing pattern related to airflow limitation and inflammatory process as manifested by labored rapid respirations and restlessness.

Inference When the retained mucous secretions are not expelled, the airway narrows. It then limits the intake of air through the nose. As airflow limitation increases, respiration also does. When there is a limitation to the airflow, the breathing pattern is disturbed.

Planning

Intervention

Rationale  To evaluate presence/chara cter of breath sounds/secreti ons.  To promote physiological ease of maximal inspiration.  To assist in taking control of the situation.  To clear secretions.

Evaluation Short term: After 8 hours of nursing intervention the patients RR decreased. Long term: After a week of nursing intervention the patient established normal breathing pattern.

Short term: Independent: After 8 hours of  Auscultate nursing intervention chest. the patients RR will decrease. Long term: After a week of nursing intervention the patient will established a normal breathing pattern.  Elevate head of bed.

Objective: + crackles upon auscultation Rapid respiration Restlessness

 Encourage slower/deeper respirations, use of pursed lip technique.  Suction airway as needed. Dependent:  Administer oxygen at lowest concentration indicated and prescribed respiratory medications.

 For management of underlying pulmonary condition, respiratory distress, or cyanosis.