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A 7-month-old patient presented with a productive cough and watery nose discharge and was admitted with a diagnosis of pneumonia. On assessment, the patient had a fever, productive cough, and watery nose discharge. The nursing diagnosis was ineffective airway clearance due to retained secretions. Interventions included maintaining airway patency, expectorating clear secretions, monitoring vital signs, changing positions, encouraging fluid intake, and deep breathing exercises. At the end of the shift, the patient's airway was patent, respiratory rate was normal, secretions decreased, restlessness was alleviated, and sleep improved.

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499 views1 page

Concept Map Pcap

A 7-month-old patient presented with a productive cough and watery nose discharge and was admitted with a diagnosis of pneumonia. On assessment, the patient had a fever, productive cough, and watery nose discharge. The nursing diagnosis was ineffective airway clearance due to retained secretions. Interventions included maintaining airway patency, expectorating clear secretions, monitoring vital signs, changing positions, encouraging fluid intake, and deep breathing exercises. At the end of the shift, the patient's airway was patent, respiratory rate was normal, secretions decreased, restlessness was alleviated, and sleep improved.

Uploaded by

midskiescreamz
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ASSESSMENT DATA OF THE PATIENT Name: L.M.

C Age: 7 months Wt: 9 kilograms cc: Productive cough with watery nose discharge Admitting diagnosis: PCAP

ASSESSMENT T: 36.9 P: 122 RR: 32 -Fever -Productive cough -Watery nose discharge

OUTCOME -Maintain airway patency -Expectorate clear secretions readily

NURSING DIAGNOSIS -Ineffective Airway Clearance related to retained secretions and excessive mucus

EVALUATION NURSING INTERVENTIONS *at the end of the shift the client was able to display patency of airway as manifested by.. - clients respiratory rate is within the normal range -client secretion decreased -client restlessness is alleviated and remained calm -client sleeping pattern is improved

DEPENDENT -watch out for cyanosis and tachypnea -start carbocisteine drops -Administer *ilosome drops T.D *Cefuroxime 200mg P.O, Q8 *paracetamol drops P.O Q.4

INDEPENDENT -monitor vital signs -change position every two hours, elevate the head -to mobilize secretions encourage adequate fluid intake -encourage deepbreathing exercises to minimize effort

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