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NCP and FDAR

Ryan, a 4-year-old male, presented with difficulty breathing, coughing, and low oxygen saturation. His vital signs showed tachypnea, high heart rate, and fever. He had a history of asthma and previous ICU admission. The nurse assessed his respiratory rate, depth, and rhythm, monitored his anxiety level and fatigue, and kept his head elevated. After 8 hours, Ryan's symptoms were relieved as his oxygen saturation increased and heart rate decreased, meeting the nurse's short term goal.

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Reysiela Mae Valino
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530 views3 pages

NCP and FDAR

Ryan, a 4-year-old male, presented with difficulty breathing, coughing, and low oxygen saturation. His vital signs showed tachypnea, high heart rate, and fever. He had a history of asthma and previous ICU admission. The nurse assessed his respiratory rate, depth, and rhythm, monitored his anxiety level and fatigue, and kept his head elevated. After 8 hours, Ryan's symptoms were relieved as his oxygen saturation increased and heart rate decreased, meeting the nurse's short term goal.

Uploaded by

Reysiela Mae Valino
Copyright
© © All Rights Reserved
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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Valino, Reysie Velle D.

BSN 2A

NCP and FDAR


Presenting Complaint:
4 year old male [Ryan] presents with difficulty breathing. Mum states child has
been tired in the last week and irritable. Noticed red rash on hands two days
ago thought it was a reaction to grass as child had been spending a lot of time
outside recently; itching profusely today with lack of sleep child has started to
stress. Coughing started 1hr ago mum gave 12xpuffs Ventolin with no relief.

Past history:
-Asthma with previous ICU admission when he was three.
-Vaccinations up to date

Vital signs:
-BP 110/72
-HR 143
-O2 Sats 92% on RA
-Temp 37.3
-Resps 34

NCP
Assessment Diagnosis Planning Interventions Evaluation
Subjective Ineffective Short Term Goal: Independent: After 8 hours of the
Data: Breathing After 8 hours of Assess the nurse’s shift, the
“Child has Pattern. R/T the nurse’s shift, respiratory rate, patient display
been tired in to asthma all nursing depth, and relieved as
the last week as evidence interventions will rhythm. evidenced by 02
and irritable” by cough maintain optimal Rat. sats: 95% and HR:
as stated by and breathing Changes in the 110 beats per
the mother. tachypnea pattern; absence respiratory rate minute.
of tachypnea as and rhythm may
Objective evidenced by indicate an early Goal Met.
Data: keeping a patent sign of impending
- tachypnea, airway. respiratory
observed distress.
cough, low Long Term Goal:
oxygen sats, Within the time Assess the
high HR than frame of client’s level of
normal admission to anxiety.
discharge patient Rat.
VS: will demonstrate Anxiety may
Temp: 37.3°C behaviors to result from the
BP:110/72 achieve airway struggle of not
HR:143 clearance. being able to
02 Sats:92% breathe properly.
RR: 34
Maintain head of
bed elevated.
Rat.
This promotes
maximum lung
expansion and
assists in
breathing.

Assess for
fatigue.
Rat.
Fatigue may
indicate distress,
leading to
respiratory failure.

Interdependent:
Assist and
monitor effects of
nebulizer
treatment and
other respiratory
physiotherapy as
ordered by
physician.
Rat.
Coordination of
treatments and oral
intake reduces
likelihood of
vomiting with
coughing,
expectorations.

FDAR
DATE/TIME FOCUS DATA, ACTION, AND RESPONSE

05/22/22 Ineffective D: “Child has been tired in the last week and
8:00 AM Breathing irritable” as stated by the mother, presence of
Pattern tachypnea, observed cough, low oxygen sats, high
HR than normal, VS: Temp: 37.3°C, BP:110/72,
HR:143, 02 Sats:92%, RR: 34----------------
—---------------Valino R.
A: Assess the respiratory rate, depth, and rhythm,
4:00 PM Assess the client’s level of anxiety, Maintain head of
bed elevated, Assess for fatigue—------------Valino R.
R: After 8 hours of the nurse’s shift, the patient
display relieved as evidenced by 02 sats: 95% and
HR: 110 beats per minute.---------—-----------Valino R.

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