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Problem # 1
Cough with Phlegm
Subjective Data
-mother verbalized nahihirapan baby ko umubo
Objective Data
-RR is 76 bpm(N-30-50 BPM) -cough with phlegm -difficulty in breathing -raising of shoulder when breathing
Nursing Diagnosis Ineffective airway clearance related to increased amount of secretion, chest pain and fatigue and weakness as evidenced by difficulty of breathing
Secretion of phlegm may contribute to obstruction in airway clearance thus resulting to difficulty in breathing Goal or Objective
After 1 hour of nursing intervention, patient will be able to demonstrate patent airway as evidenced by ability to cough up secretions and deep breathe.
Intervention
Independent
1. Assist patient with or instruct effective deep breathing and coughing with upright position.
Promote lung expansion, remove secretions.
3. Assess for pain or discomfort and medicate on a routine basis and prior to breathing exercises.
Encourages the patient to cough more effectively and breathe more deeply to prevent respiratory insufficiency.
7. Suction if needed.
It clears secretion.
Evaluation
Goal met. Patient was able to breathe well. He demonstrated proper coughing technique and was able to secrete phlegm.
Problem # 2
Difficulty of breathing
Objective Data -RR is 76 (N:30-50bpm) -forceful cough -difficulty in breathing -raising of shoulder when breathing
Nursing Diagnosis Impaired gas exchange related to ventilation perfusion imbalance Exchange of gases is being affected due to bronchospasm resulting from constriction of bronchial smooth muscle
Goal or Objective After 2 hours of nursing intervention, patient will be able to have airway clearance and increased respiratory response as evidenced by having respiratory rate within normal range, which is 30-50 breaths per minute.
Intervention Independent
1.Position patient in proper body alignment for optimal breathing pattern. Allows lung excursion and chest expansion. (Gulanick,1998:28) 2. Tech patient appropriate breathing, coughing, and splinting technique. Facilitate adequate clearance of secretions. (Ibid.) 3. Explain effects of wearing restrictive clothes.
So that exertion is not compromised. (Ibid.)
Evaluation
Goal partially met. Patients respiration rate was decreased to 70 bpm. He was able to remove secretions and verbalized improvement in comfort.
Subjective Data
-father verbalizedmy son getting thinner
Nursing Diagnosis Activity intolerance related to decreased muscle strength secondary to poor nutritional intake as evidenced by weak hand grip
Goal or Objective
After 2 hours of nursing intervention, patient will be able to decrease fatigue level as evidence by relaxed appearance.
Intervention Independent 1. Encourage several rest periods. During rest, energy is conserved and levels are replenished several shorter rest periods may be more beneficial than one longer rest period. (Smeltzer, 2004:336) 2. Encourage patient to ask assistance when doing something to reduce workload. It conserves energy. (Ibid) 3. Encourage adequate protein and calorie intake. Protein and calorie depletion decreases activity tolerance. (Ibid) 4. Encourage use of relaxation techniques. Promotion of relaxation and psychological rest decreases physical fatigue. (Ibid) 5. Increase total hour of night time sleep. Sleep helps to restore energy levels. (Ibid)
Evaluation
Goal met. Patient appeared to be relaxed. Patient verbalized of comfort.
Nursing Diagnosis Risk for infection related nosoconial infection secondary due to poor hygine Nosoconial infection is an infection whose development is favoured by a hospital environment, such as one acquired by a patient during a hospital visit or one developing among hospital staff such as handwashing.
Goal or Objective
After 2 hours of nursing intervention, patient will be able to demonstrate normal temperature and preventive measures to avoid infection.
Intervention Independent 1. Monitor vital sings especially temperature. Increased body temperature indicates infection. Sings and symptoms of infection may be diminished in the host if there is subsequent initiation therapy. (Smeltzer, 2004: 334)
Evaluation
Goal met. Patients temperature was 36.8 C. Patient parents also performed hand washing but still assisted by wife.