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> Rationale- Keeping the head elevated lowers diaphragm, promoting chest expansion, aeration of lung segments, and mobilization and expectoration of secretions to keep the airway clear. 
Dependent 
 Administer nebulizer (eg. salbutamol) as indicated 
Rationale- Facilitates liquefaction and removal of secretions. 
Evaluation 
 Goal met. After 2 hours of duty, patient manifests improve breathing pattern and comfort. 
Date: 
Subjective cues 
 No subjective cues noted 
Objective cues 
 V/S: 
 Generalized weakness 
 On NGT feeding 
 On Intravenous Fluid at 60-70 microgtts/min 
 On 02 inhalation at 2-4 L/min 
 Glasgow Coma Scale of 6 
• Eye opening – no response – 2 
• Motor response – extends abnormally – 2 
• Verbal response – no response – 2 
Nsg. Dx. 
 Risk for infection related to present illness 
Planning 
 After 3 days of duty, patient will be prevented from infections. 
Intervention 
Independent 
 Stressed proper hand washing technique. 
Rationale- Reduces risk of cross-contamination. 
 Assessed vital signs especially temperature. 
Rationale- Arise in pulse and temperature may provide warning of infectious process unless patient’s immune system is too compromised to respond. 
 Maintained sterile technique for invasive procedures. 
Rationale- Prevents entry of bacteria, reducing risk of nosocomial infections. 
 Encouraged frequent position changes every two hours, as indicated. 
Rationale- Limits stasis of body fluids, promotes optimal functioning of organ systems, GI tract. 
 Kept manipulations of enteral feeding system to a minimum and wash hand before opening system. 
Rationale- Touch contamination of formula is caused by care giver administration. 
Dependent 
 Administer antibiotics (e.g. cefimax) 
Rationale- antibiotics can kill potentially harmful bacteria by disrupting their cell wall synthesis, thus reducing the risk of infection. 
Evaluation 
> Goal met. After 3 days of duty, patient have no manifestation of infection. 
Subjective cues 
 “Jari sija tagpaoxygen kay naglisud man sija pag-ginhawa” as verbalized by SO 
Objective cues 
 With O2 inhalation at 2-4 L/min 
 Wheezing sound noted upon auscultation 
 Audible rales heard at left base upon auscultation 
 Breathing pattern shallow and rhythmic upon inspection 
 RR: 34 cpm; HR: 140 bpm; T: 40 C 
Nsg. Dx. 
 Impaired Gas Exchange r/t Alveolar – capillary membrane changes (inflammatory effects) as manifested by dyspnea & tachycardia 
Planning 
 After 6 hours of applying nursing care patient will demonstrate improved ventilation & oxygenation by tissues of ABGs within patient’s acceptable range and absences of symptoms of respiratory distress. 
Intervention 
Independent 
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