A.

Nursing Care Plan Nursing Interventio ns 1# Short ;erm: Establish A+ter 4 = > ra))ort to hours o+ the )atient# nursing /ationale: interventions to gain the the )atient?s trust and res)iration coo)eratio will im)rove n# and di++icult" %# assess o+ breathing )atient?s will be condition# relieve# As /ationale: evidence b" a to know normal and res)iration determine rate o+ 1@A the %2c)m a )atient?s normal need# &ardiac rate 4# Bonitor o+ @2A and record 122b)m the C5S# clear breath /ationale: sounds and to establish )revent the baseline used o+ data# accessor" ># muscles auscultate lung +ields (ong ;erm: noting A+ter 4 = > areas o+ da"s o+ decrease5a nursing bsent interventions air+low and the )atient adventitiou ma" maintain s breath a )atent sounds# airwa"# As /ationale: evidence b" a to identi+" normal the areas Planning

Assessment

Need P 7 8 S I $ ( $ 9 I & A ( N E E D $ : 8 9 E N A ; I $ N

Nursing Diagnosis Im)aired gas e,change related to alveolar ca)illar" membrane changes such as )neumoconiosis Secondar" to communit" ac<uired )neumonia as evidenced b" di++icult" o+ breathing res)irator" rate o+ %0 c"cles )er minute )ulse rate o+ 12% beats )er minute )ositive whee!es at right lower thora, use o+ accessor" muscles and )ale in a))earance /ationale: ;he )resence o+ )uss and accumulation o+ e,cessive )leural cavit" lessens the range o+ lung e,)ansion thereb" decreasing the amount o+ air that enters the lungs#

Evaluation 9oal met: A+ter 4 = > hours o+ nursing interventions the )atient?s res)iration shall have im)roved and di++icult" o+ breathing shall have been relieved As evidence b" a normal res)iration rate o+ 1@A %2c)m a normal &ardiac rate o+ @2A122b)m clear breath sounds and )revent the used o+ accessor" muscles

Subjective cue: Naglisod ko og ginhawa as verbali!ed b" the client# $bjectives: $% ihalation via N& ' %()m *se o+ accessor" muscle in breathing Positive whee!es at right lower thora, Pale in a))earance Dr" li)s Productive cough -"ellowish s)utum. //:%0c)m P/:12%b)m 3P:142562mm

(ong ;erm: A+ter 4A> da"s o+ nursing interventions the )atient will have been able to maintain a

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res)iration rate o+ 1@A %2c)m and a normal &ardiac rate o+ @2A 122b)m clear breath sounds and )revent the used o+ accessor" muscles

o+ consolidati on and determine )ossible bronchos) asm or obstruction # D# Assist )atient to change )osition ever" 42 min# /ationale: to mobili!e secretions# @#)rovide health teachings regarding e++ective coughing and dee) breathing e,ercise# /ationale: to e,)el the mucous# 6#encourag e to increase +luid intake# /ationale: to li<ue+" secretions E administer mucol"tics as )rescribed# /ationale: Bucus

)atent airwa"# As evidence b" a normal res)iration rate o+ 1@A %2c)m a normal &ardiac rate o+ @2A122b)m clear breath sounds and )revent the used o+ accessor" muscles

viscosit" 0 Administer antibiotics as ordered and monitor +or side e++ects /ationale: Avoids +urther multi)licati on o+ microorgan ism 12administ er bronchodil ators as recommen ded# /ationale: 7el) enhance )assage o+ air to the airwa"

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Assessment Subjective cues: Dle ko makalihok og ako ra d)at naa jud ako banta" as verbali!ed b" the client# P 7 8 S I $ ( $ 9 I &

NEED

Nursing Diagnosis Activit" intoleranc e related to bed rest or immobilit" as evidence b" shortness o+ breath a+ter re)ositioni ng //: %4 c"cles )er minute noted bod" weakness di++icult" maintainin g balance observed bod" malaise and discom+or t and +acial grimace#

Planning Sort ;erm: A+ter E hours o+ nursing interventio ns the )atient will be able to identi+" techni<ues in enhancem ent o+ activit" tolerance as evidenced b": Aeu)nea a+ter re)ositioni ng Aincreased bod" strength Abalance stabilit"

Nursing Intervention s 1# Evaluate current limitations5d egree o+ muscle strength# /ationale: Provides com)arative baseline data# %# Assess emotional5) s"chologic +actors a++ecting the current situation# /ationale: Determines whether this +actor aggravates underl"ing cause 4# Adjust activities de)ending on client?s tolerance# /ationale: )revents overe,ertio n# ># Per+orm /$B e,ercise as necessar"# /ationale: 7el)s increase client?s muscle strength# D# Plan care with rest )eriods between activities# /ationale: /educes +atigue

Evaluation 9oal met: ;he )atient will be able to identi+" techni<ue s in enhancem ent o+ activit" tolerance as evidenced b": Aeu)nea a+ter re)ositioni ng Aincreased bod" strength Abalance stabilit" A decreased muscle )ain and com+ort Agood +acial gestures

$bjective cues: $% ihalation via N& ' %()m Shortness o+ breath a+ter re)ositioning 3od" weakness Facial grimace Di++icult" maintaining balance $bserved bod" malaise and discom+ort Pale in skin color Dr" li)s Productive cough -"elllowish s)utum. //: %0 c)m P/: 12% 3P:142562mm7g

N E E D AAAAAAAAAAAAA Activit" intoleranc e

A decreased /ationale: muscle Activit" )ain and intoleranc com+ort e is due to lessen Agood movemen +acial t re+usal gestures o+ the client to go out o+ bed and decrease d e,ercise and range o+ motion# ;hus it results to decrease d circulation

ASSESSMEN T / Subjective cues: *saha" mag Galintura si mama as verbali!ed b" her watcher $bjective cues: $n and $++ Fever o+ 4E#1H& $% ihalation via N& ' %()m *se o+ accessor" muscle in breathing Positive whee!es at right lower thora, Pale in a))earance Productive cough -"ellowish s)utum. //:%0c)m P/:12%b)m 3P:142562mm7g I S G F $ / I N F E & ; I $ N

NEED

NURSI NG DIAGN OSIS /isk +or in+ectio n related to inade<u ate second ar" de+ense second ar" to )neumo nia /ational e: ImmunoA su))ressi on due to decrease in hemoglobi n leuko)eni a and su))ress in+lammat or" res)onse gives a greater o))ortunit " +or )athogeni c bacteria to invade and inoculate in a s)eci+ic bod" )art o+ a susce)tibl e human bod"# ;hus leading to a +urther damage or

PLANING Short term A+ter @ hours o+ nursing interventio ns she will verbali!e that she understan d the individual causative5 risk +actors and demonstr ate li+est"le changes to )revent +urther in+ection# Long term A+ter 4A> da"s o+ nursing interventio ns the )atient will be +ree +rom )ossible s)read o+ in+ection#

NURSING INTERVENTI ONS 1# Bonitor v5s closel" es)eci all" during initiatio n o+ thera)" # / ;o know )otenti al +atal com)lic ation that ma" occur#

EVALUATIO N Short term ;he )atient?s mother shall have verbali!ed her understandin g o+ individual causative5ris k +actors and demonstrate li+est"le changes to )revent +urther in+ection# Long term ;he )atient shall have been +ree +rom )ossible s)read o+ in+ection#

%# Assess de)th5r ate o+ res)irat ion and chest movem ent# / ;ach") nea shallow res)irat ion and as"mm etric chest movem ent are +re<uen tl" )resent ed becaus e o+

!. Dis"harge Plan Instructed +or the Bedication com)liance o+ medication 1# Encourage the )atient to com)l" with the )rescribed medication# I ;his )revents +urther develo)ment o+ the disease )rocess and other )ossible com)lication# %# Jarn them about the side e++ects that ma" occur# 1# I Side e++ects are e,)ected aside +rom its thera)eutic e++ects or action# It is im)ortant to Fre<uenc"5 dosage ;ime

discuss to them the side e++ects to )revent con+usion#

4# Instruct them that the" should not give drugs which are not )rescribed b" the )h"sician# I ;o avoid the ine++ectiveness o+ the drug )rescribed and to ensure the sa+et" o+ the client# Instructed +or regular )rescribed e,ercise# E,ercise Fre<uenc" ;ime

1# Per+ormed /$B e,ercises like +le,ion and e,tension o+ e,tremeties as tolerated# I /ela, the muscle %# Instruct to do dee) breathing and coughing e,ercise# As needed As needed Ever" DA12 minutes# @:22 am

I to )romote lung e,)ansion and e,)ectorate secretions easil" Instructed +or recommended ;reatment treatment to treat5 lessen underl"ing illness# 1# $bserve )ro)er %A4 minutes )rior5a+ter to handling things or 3e+ore eating and or a+ter handling )ersonal h"giene to avoid com)lication# Fre<uenc" ;ime

I ;o avoid rein+ection +re<uent hand washing# Encouraged to take a bath# I 7"giene is im)ortant to )revent ac<uiring other disease or in+ections# Im)arted health 7ealth ;eaching teachings to im)rove health condition# 1# Assist the client in turning to sides# I to mobili!e secretions and )revent )ulmonar" embolism %# Instruct to clean the surroundings +ree +rom allergen# Fre<uent change in )osition Fre<uenc" $nce a da"

eating utensils#

6:22 am

;ime

Ever" time

% times a da" or as needed

@:22am D:22 )m or as needed

I ;o avoid stimulation o+ cough# 4# Per+ormed back ta))ing a+ter nebuli!ation# I ;o increase the +orce in e,)ectorating secretions# ># Encourage to increase oral +luid intake# I It aids in mobili!ation and e,)ectorating secretions# Advised )atient to visit $utAPatient +or checkAu) to the doctor +or +urther +ollowA u) o+ health status# 1# Advise )atient to visit +or checkAu) to the doctor +or +urther +ollowAu) o+ health status# I ;o evaluate the )rogress o+ the treatment and condition# $nce a month From the time she e,)erience uncom+ortable asthma attack# or Fre<uenc" ;ime E glasses o+ water in a da" As needed 1A% minutes a+ter nebuli!ation A+ter nebuli!ation

Diet

Instructed +or )ro)er nutrition#

Fre<uenc"

;ime

1#

Encourage

)atient to eat +oods rich in )rotein vitamin c and +iber# I ;o su))ort immune s"stem and to )romote in+ection resistance 4 times a da" A+ter eating