NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: Acute pain r/t • Pneumonia is • After 4 hours • Elevate head of • Lowers • After 4
localized of nursing the bed, change diaphragm, hours of
“Masakit ang inflammation and
inflammation
interventions position promoting nursing
dibdib ko” as persistent cough. of the terminal , the patient frequently. chest intervention
verbalized by airways and will display expansion s, the
patient. alveoli caused patent and patient was
by acute airway with expectoration able to
Objective: breath of secretions. display
infection by
sounds • Assist patient • Deep patent
• Use of various clearing and with deep breathing airway with
accessory agents. absence of breathing facilitates breath
muscle. Pneumonia dyspnea. exercises. maximum sounds
can be divided expansion of clearing and
• Dyspnea into three the lungs and absence of
smaller dyspnea.
groups:
• Fatigue. airways.
community • Demonstrate or • Coughing is a
• V/S taken as acquired, help patient natural self
follows: hospital or learn to perform cleaning
nursing home activity like mechanism.
T: 37.3 acquired splinting chest Splinting
P: 80 and effective reduces chest
(nosocomial), coughing while discomfort,
R: 25
Bp: 120/80 and in upright and an upright
pneumonia in position. position favors
an deeper, more
immunocompr forceful cough
effort.
omised
• Force fluids to at • Fluids
person. least 3000 ml especially
Causes per day and offer warm liquids
include warm, rather aid in
bacteria than cold fluids. mobilization
(Streptococcu and
expectoration
s,
of secretions.
Staphylococcu
s,
Haemophilus Collaborative:
influenzae, • Administer • Aids in
medications as reduction of
Klebsiella,
prescribe: bronchospas
Legionella). mucolytics or m and
Community expectorants. mobilization of
Acquired secretions.
Pneumonia • Provide • Fluids are
(CAD) is a supplemental required to
fluids. replace losses
disease in and aid in
which mobilization of
individuals secretions.
who have not
recently been
hospitalized
develop an
infection of the
lungs. It is an
acute
inflammatory
condition
that’s result
from
aspiration of
oropharyngeal
secretions or
stomach
contents in the
lungs.