SALTA, MARY JADE T.
PATIENT: Binuya, Lee Anne
BSN 139 1 yr and 6 mos. old
GROUP 155 INSTITUTE OF NURSING Dx: Acute Respiratory Infection
ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
OBJECTIVE:
Abnormal Ineffective
Acute respiratory After 8 hours Assess respirations Prevents After 8
infections (ARIs)
breath continue to be the of nursing for rate (count for repetition of hours of
airway leading cause of
sounds intervention one full minute), information nursing
wheezes Clearance acute illnesses
the patient depth and ease, and promotes interventi
worldwide and
upon related to remain the most will return to presence of compliance ons, the
productive important cause baseline
auscultation tachypnea, necessary to patient
of infant and
Changes in secretions young children parameters dyspnea and if it maintain will be
rate or mortality, for rate, occurs during sleep normal glucose able to
accounting for
depth of about two million depth and or quiet time; note level. cough up
respirations deaths each ease. panting, nasal and
year and ranking
Fever first among
flaring, grunting, remove
causes of retracting, slowing, secretions
MEASURABLE disability-adjusted deep or shallow that are
life-years (DALYs)
CUES: lost in developing breathing, stridor thin and
T- 37 C countries (94.6 on inspiration, clear.
millions, 6.3% of
PR- 136 total. The
head bobbing
RR- 37 populations most during sleep.
at risk for
developing a fatal
respiratory Assess breath
disease are the sounds by Provides
very young, the
SALTA, MARY JADE T. PATIENT: Binuya, Lee Anne
BSN 139 1 yr and 6 mos. old
GROUP 155 INSTITUTE OF NURSING Dx: Acute Respiratory Infection
ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
elderly, and the auscultation, indication of
immunocompromi
sed. While upper consolidation by patent airways
respiratory percussion and by
infections (URIs)
are very frequent
fremitus. auscultation,
but seldom life- revealing
threatening, lower crackles heard
respiratory
infections (LRIs) in the presence
are responsible of
for more severe
illnesses such as secretions(fine
influenza, and coarse)
pneumonia,
tuberculosis, and
rhonchi
bronchiolitis that (audible and
are the leading palpable) in
contributors to
ARIs' mortality. larger airway
obstruction
and wheezes in
small
bronchiolar
narrowing,
diminished
breath sounds
SALTA, MARY JADE T. PATIENT: Binuya, Lee Anne
BSN 139 1 yr and 6 mos. old
GROUP 155 INSTITUTE OF NURSING Dx: Acute Respiratory Infection
ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Assess skin color in presence of
changes, decreased
distribution and airflow and
duration of lung
cyanosis (nail beds, consolidation.
skin,mucous
membranes, Reveals
circumoral) or presence and
pallor. degree of
cyanosis,
indicating an
uneven
distribution of
gas and blood
in the lungs,
and alveolar
hypoventilation
resulting from
airway
obstruction,
the weakness
SALTA, MARY JADE T. PATIENT: Binuya, Lee Anne
BSN 139 1 yr and 6 mos. old
GROUP 155 INSTITUTE OF NURSING Dx: Acute Respiratory Infection
ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
of muscles
used in
Assess cough respiration or
(moist, dry, respiratory
hacking, center
paroxysmal, depression.
brassy, or croupy):
onset, duration, Reveals
frequency, if characteristics
occurs at night, of cough as an
during day, or indication of a
during respiratory
activity;mucus condition that
production: when may be
produced, amount, produced by
color infection or
(clear,yellow,green inflammation;
), consistency small and
(thick, tenacious, narrow airways
frothy; ability to of an
expectorate or if infant/child
SALTA, MARY JADE T. PATIENT: Binuya, Lee Anne
BSN 139 1 yr and 6 mos. old
GROUP 155 INSTITUTE OF NURSING Dx: Acute Respiratory Infection
ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
swallowing and the
secretions, stuffy difficulty to
nose or nasal cough up
drainage. secretions,
which lead to
infection and
Reposition on sides change in
every 2 hours; respiratory
position child in status.
proper body
alignment. Prevents
accumulation
Provide fluids as and pooling of
frequent intervals secretions.
over 24-h time
periods, specify
amounts; Maintains
encourage clear hydration
liquids, and avoid status, and
milk clear liquids
liquiefy and
SALTA, MARY JADE T. PATIENT: Binuya, Lee Anne
BSN 139 1 yr and 6 mos. old
GROUP 155 INSTITUTE OF NURSING Dx: Acute Respiratory Infection
ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
mobilize
Provide periods of secretions;milk
rest by organizing tends to
procedures and thicken
care and disturbing secretions.
infant /child as
little as possible in Prevents
acute stages of unnecessary
illness. energy
expenditure
Provide toys, resulting in
games for quiet fatigue.
play and a quiet
environment.
Prevents
excessive
energy
expenditure
and need for
additional
oxygen
SALTA, MARY JADE T. PATIENT: Binuya, Lee Anne
BSN 139 1 yr and 6 mos. old
GROUP 155 INSTITUTE OF NURSING Dx: Acute Respiratory Infection
ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
consumption
which changes
respiratory
status while
still providing
Administer moderate
medications orally, activity and
parenterally diversion o
according to the play.
physician order.
Specify drug
Instruct action.
parents/child in
handwashing
techniques.
Prevents
transmission of
microorganism
s from touching
Instruct parents/ face of child by
SALTA, MARY JADE T. PATIENT: Binuya, Lee Anne
BSN 139 1 yr and 6 mos. old
GROUP 155 INSTITUTE OF NURSING Dx: Acute Respiratory Infection
ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
child to avoid parent(s)/child
contact with those without
who have handwashing.
respiratory
infections. Prevents
transmission of
Teach parents and microorganism
possibly older child s via airborne
(specify) droplets.
administration of
medication via
proper route with Ensures
name and action of compliance
each drug. with correct
drug dosage
and other
considerations
for
administrations
for desired
results, and
SALTA, MARY JADE T. PATIENT: Binuya, Lee Anne
BSN 139 1 yr and 6 mos. old
GROUP 155 INSTITUTE OF NURSING Dx: Acute Respiratory Infection
ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
what to do if
side effects
occur.
