Nursing SOAPIE - Cough, child

S> "Gi-ubo lagi siya, maglisod na nuon ug ginhawa ( he has cough which makes it difficult for him to breathe well)", as verbalized by the S.O.
O> Received patient with D5LR 1L @ 400cc level, regulated @ 25cc/hr
> Temp 37C, PR 130bpm, RR 45cpm
> Cough noted, productive
A> Ineffective airway clearance: productive cough related to tracheobronchial infection
secondary to pneumonia.
Note: the secondary factor, that is pneumonia, came from the doctor's diagnosis, as
extracted from the patient's record.
P> After 1 hr of nursing intervention, the patient will be able to effectively cough out secretions.
I> Assessed respiration, noted quality, rate, pattern, depth, and use of accessory muscles.
> Assessed changes in vital signs.
> Assessed effectiveness to cough out.
> Noted presence of sputum.
> Given Salbutamol syr, 3ml as ordered
E> "Arang-arang na iyang ginhawa (he can breath better now)", as verbalized by the patient's
mother.