Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective Data -Ineffective Airway Short – Term Goal Independent -After 15 mins. of nsg.

• Pale and weak Clearance related to intervention pt. has

in appearance excessive sputum -After 15 mins. of -v/s taking -To establish a data normal breathing and

• Dry mucous production Nsg. Intervention base. enable to sleep

membrane pt. will maintain comfortably.

-Hyperthermia related to airway patency. -Tepid sponge bath -To open pores and
• Lack of tears
disease process as release excess heat -After 30 mins. of
when crying
evidenced by weak and -After 30 mins. of in the body. continuous T.S.B
• Excessive
pale appearance Nsg. Intervention -Remove excess -To promote client’s temp. subsides
sputum
client’s temp. will blankets comfort and to 37.4 ۫C

-Fluid volume deficit subside to 37.5 ۫C ↓ prevent convulsion.

Measurable Data
related to frequent -After 8 hours of duty
V/S
vomiting and LBM. Long – Term Goal -Increase fluid intake -To prevent further pt. has better fluid
T – 38.1
dehydration volume as evidenced by
RR – 59 cpm
moist mucous
PR – 154 bpm -After 8 hrs. of
-Measure accurate I/O -To assess fluid membrane.
duty pt. will volume

maintain fluid
-Assist with the use of -To mobilize
volume at
respiratory devices and secretions
functional level
treatments (nebulizer)

- provide health -To enhance Health

teachings to parents awareness

(importance of hand

washing)

NCP