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NURSING CARE PROCESS

ASSESSMENT NURSINGDIAGNOSIS

RATIONALE GOAL NURSINGINTERVENTION

RATIONALE EVALUATION

Subjective cues:Nahihirapan nasiya humingadahil sa plemahindi niyamailabas grabena!asi ang ub" niyaneh# as $erbali%edby his m"&her

Objective cues:>difficulty of

breathing

'(hee%es "n

b"&h lung )ields

'pr"du*&i$e *"ugh

+ ,hi&ish *"l"r

'nasal )laring

Ine))e*&i$e air,ay*learan*e rela&ed

&" ine))e*&i$e

*"ugh and

re&ained

se*re&i"ns-

The in)lamma&"ryresp"nse &"

in)e*&i"n *auses

&issue edema and

e.uda&es )"rma&i"n

in &he lungs &he

in)lamma&"ry

resp"nse *an

narr", andp"&en&ially "bs&ru*&

br"n*hial passages

and al$e"li-

Sh"r& Term/

A)&er 0 h"urs ")

nursing

in&er$en&i"ns &he

*lien& ,ill be able

&" main&ain air,ay

pa&en*y-

L"ng Term/

A)&er 1 day ")nursingin&er$en&i"n &he

*lien& ,ill beable &"e.pe*&"ra&e

re&ainedse*re&i"ns andmain&ain n"rmal

'Assessedrespira&"ry

m"$emen&s and use

") a**ess"ry

mus*les-

'M"ni&"red $i&al

signs espe*ially &he

RR-

'Aus*u&a&ed &he

lung s"unds n"&ing

areas ") de*reased

$en&ila&i"n and

presen*e ")

ad$en&i&i"us s"unds-

'M"ni&"red *hes& .

'Use ") a**ess"rymus*les &" brea&he

indi*a&es an abn"rmal

in*rease in ,"r! ")

brea&hing-

'T" "b&ain baseline

da&a- )

'2r"n*hial lung

s"unds are *"mm"nly

heard "$er areas ")

lung densi&y "r

*"ns"lida&i"n-

3ra*!les are heard

,hen )luid is presen&-

'These de&ermine

The *lien&main&ained air,ay

pa&en*y as

e$iden*ed by

e.pe*&"ra&ing *lear

se*re&i"ns readily-

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'res&lessness brea&hingpa&&ern-

+ ray rep"r&s-

'En*"uraged *lien&

&" in*rease )luidin&a!e-

'Ad$ised &he

real&i$es ele$a&e &he

head ") bed a& leas&

45 degrees-

'Assis&ed "n

nebuli%er &rea&men&-

Nebuli%a&i"n d"ne

as per d"*&"r6s "rder

e$ery 17 h"urs-'3hes& &apping

pr"gressi"n ") disease

pr"*ess- )

'8ydra&i"n helps

de*rease &he $is*"si&y") se*re&i"ns

)a*ili&a&ing

e.pe*&"ra&i"ns-

'9"si&i"ning )a*ili&a&es

*hes& e.pansi"n and

respira&"ry e))i*ien*y

by redu*ing pressure") abd"minal "rgans

"n diaphragm-

' Rela.es br"n*hial

and u&erine sm""&h

mus*le by a*&ing "n

be&a + adrenergi*

re*ep&"rs-'3hes& physi"&herapy

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per)"rmed a)&er

ea*h nebuli%a&i"n-

'Ins&ru*&ed &he*lien& &" ha$e "ral

*are a)&er ea*h

nebuli%a&i"n-

'9r"$ided

supplemen&al )luids

helps &" aid

imm"bili%a&i"n ")

se*re&i"ns-

'Dis*harges )r"m &henebuli%er are ")&en )"ul

&as&ing and smelling-

':luids are regula&ed

&" repla*e l"sses and

aid imm"bili%a&i"n

se*re&i"ns-

ASSESSMENT NURSINGDIAGNOSIS

RATIONALE GOAL NURSINGINTERVENTION

RATIONALE EVALUATION

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Sub;e*&i$e Da&a/

Ta&l"ng ara, ngpabali!-? @3

8yper&hermiarela&ed &"in)lamma&"ryresp"nse-

In*rease in b"dy&empera&uregrea&er &hann"rmal range-

En&ry ") &hepa&h"gen in

*ir*ula&"ry sys&em

Regula&i"n ") &".ins

in &he b"dy

Release ") pyr"gen

S&imula&i"n ") &hehyp"&halamus

In*rease "ral&era&i"n ")

&herm"regula&i"n

In*rease in b"dy

&empera&ure

8yper&hermia

A)&er 7 h"urs ")e))e*&i$enursing in&er$en&i"n&he pa&ien&6s&empera&ure ,illde*rease/

'Dem"ns&ra&e&empera&ure ,i&hinn"rmal range )r"m4>-? @3 &" 4B-C@3

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'Verbali%edunders&anding ")spe*i)i*in&er$en&i"ns &"pre$en&

hyper&hermia

'9r"$ide TS2 asneeded

'9r"m"&e sur)a*e

*""ling l""sen*l"&hing and *""len$ir"nmen&

'Re$ie, spe*i)i*ris!)a*&"rs *ausessigns andsymp&"ms ,i&h&he in&er$en&i"nsre uired

'Dis*ussimp"r&an*e ")ade ua&e )luidin&a!e andpr"&ein die&

3"llab"ra&i$e/

'Adminis&ermedi*a&i"ns asindi*a&ed &"&rea& underlying*ause su*h as/

'8ea& is l"ss bye$ap"ra&i"n and*"ndu*&i"n-

'8ea& is l"ss by3"n$e*&i"n

radia&i"n and*"ndu*&i"n-

'T" pr"m"&e,ellness

'T" pre$en&dehydra&i"n

'T" &rea&

underlying*auses

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diarrhea-

' Res&ar& "ral )luidin&a!e gradually-

O))er *lear li uidsh"urly and a$"id*"ld )luids-

' En*"urage &" ea&

)""ds li!e bananaand apple

' A$"id )""ds &ha&are "ily spi*y and*a))eine-

3"llab"ra&i$e/' Adminis&er an&i