Von Mark Ungos

2BSN-06

Nursing Care Plan

Assessment Nursing Diagnosis Nursing Analysis Planning Nursing Intervention Rationale Evaluation

Name: Ineffective airway Pneumonia is an excess After 4 hours of nursing -Assess Respiratory -Indicative of respiratory After 4 hours of nursing
Brent Soriano clearance related to of fluid in the lungs intervention the patient reate, depth and ease distress and/or intervention the
Diagnosis: excessive mucus resulting from an would be able to: accumulation of secretion patient:
PCAP C secondary to inflammation process. -Monitor body (mucus)
pneumonia The inflammation is -Lower the temperature temperature -Lower the
 Subjective triggered by many to normal -High fever greatly increase temperature to normal
“Inuubo at organism and by -Limit visitors metabolic demands and
nilalagnat ang inhalation of irritating -Maintain airway oxygen consumption and -Maintain airway
anak ko as agents, infectious patency -Institute isolation alters cellular oxygenation patency
verbalized with pneumonia are precaution
patient mother” categorized as (CAP) -Display absence of -Reduce likelihood of -Display absence of
Community Acquired dyspnea cause by mucus -Elevate head of the exposure to other dyspnea cause by plem
 Objective: Pneumonia bed and change infectious pathogen
V/S taken as position every 2 hours -The goal is met
follows - Isolation technique may
br desired to prevent
T- 37.2 spread and protect patient
P-110 from other infectious
RR- 30 process

-Promotes Expectoration