Assessment

Explanation of the Problem

Goals and Objectives STO : After 3 hours of nsg. Intervention the patient will demonstrate behaviors to improve or maintain clear airway : After 3 hours of nsg. Intervention the patient will be able to expectorate secretions readily

Nursing Intervention Dx periodic assessment of rate, depth & effort of respiration Assess Temp and pulse periodically Auscultate lung fields

Rationale gives indications as to extent of resp. difficulty or relief the client will experience Serves as a baseline data because inc. in v/s reflect increasing diff. in respiration To determine areas of decreased airflow in the lower resp. system, which may aggravate diff. of breathing and coughing to maintain open airway in at-rest

Evaluation >Goal met if After 3 hours of nsg. Intervention the patient will demonstrate behaviors to improve or maintain clear airway > Goal met if After 3 hours of nsg. Intervention the patient will be able to expectorate secretions readily >Goal met if After 3 days of nsg. Intervention the patient will demonstrate absence/reduction of congestion with clear breath sounds, noiseless respiration an improved oxygen exchange

S> May ubo siya at Irritants enter the URT may ksamang plema as verbalized by his Causes Irritation to the mother nasal mucosa O > RR 38 > Nasal flaring noted > breathes through mouth > stridor noted > with good suck A> ineffective airway clearance related to presence of secretions at the tracheo bronchial tree Stimulates moderate to excessive mucus production Cough as if not able A defense to expecto Mechanism rate To remove mucus Irrirtants

LTO : After 3 days of nsg. Intervention the patient will demonstrate absence/reduction of Blocks airways congestion with clear breath sounds, noiseless respiration an improved Amt of air that enters is oxygen exchange decreased Breathes through mouth Nasal flaring Difficulty of breathing

Tx Position head midline w/ flexion approp. For age frequent position changes

mobilizes secretions for easier expectoration

 offer 1 glass of water to client

maintains moisture of mucus membranes, thus preventing irritation and further mucous secretions encourages cooperation and participation of the client to mobilize secretions to lessen fatigue

Edx Explain every procedure to the mother of the client Encouraged deep breathing and coughing exercises Encourage to have adequate rest periods

Assessment S> Mejo mainit ang aking pakiramdam O febrile T > 38.5 warm to touch flushed skin dry oral mucosa

Explanation of the Problem Bacteria enters the respiratory tract Lodges in the lungs Proliferation of bacteria in the cells Release of bacterial endotoxins reaches Hypothalamus Altered thermoregulatory status

Goals and Objectives STO : after 2 hours of nursing intervention the patients temperature will drop from 38.5 to 37.5

Nursing Intervention Dx Monitor respirations Note presence/absence of sweating as body attempts to inc. heat loss by evaporation, conduction and diffusion Tx Maintain bed rest

Rationale hyperventilation may initially be present Evaporation is dec. by envt factors of high humidity and high ambient Temp. to reduce metabolic demands/ O2 consumption to meet inc. metabolic demands to prevent injury to treat underlying cause

Evaluation > Goal met if after 2 hours of nursing intervention the patients temperature will drop from 38.5 to 37.5

A> Altered thermoregulatory status: hyperthermia related to ongoing infectious process

LTO : after 3 days of nursing intervention the patient will be able to demonstrate behaviors to monitor and promote normothermia

> Goal met if after 3 days of nursing intervention the patient will be able to demonstrate behaviors to monitor and promote normothermia

Provide high calorie diet Ensure safety Administer meds as ordered

Hyperthermia

Edx Discuss the importance of adequate fluid intake Instructed to lessen clothing

to prevent dehydration

to promote core cooling