ASSESSMENT

NURSING DIAGNOSIS

RATIONALE

OBJECTIVES

NURSING INTERVENTIONS

RATIONALE

EXPECTED OUTCOMES

- with unproductive cough -with wheezes and crackles auscultated on both lungfields. - presence of clear watery discharge from her nose (+)restlessness -(+) irritability

Ineffective airway clearance related to presence of secretions secondary to pneumonia.

Short Term: After 4-5 hours of nursing interventions, the patients respiration will improve and difficulty of breathing will be relieved. Long Term: After 3 4 days of nursing interventions, the patient will maintain a patent airway.

1. Establish rapport to patient and SO

2. Assess patients condition

3. Monitor and record V/S 4. Auscultate lung fields, noting areas of decreased/abs ent airflow and adventitious breath sounds 5. Assist patient to change position every 30 minutes 6. Elevate head of bed and

1. To gain the trust and Short Term: cooperation After 3-4 2. >To know hours of and nursing determine interventions, patients the patients needs respiration shall have improved and 3. >To difficulty of establish breathing base line shall have data been relieved. 4. >To identify areas of Long Term: consolidatio n and After 3 4 determine days of possible nursing bronchospa interventions, sm or the patient obstruction. will have been able to 5. >To maintain a mobilize patent

align head in the middle 7. Provide health teachings regarding effective coughing and deep breathing exercise. 8. Encourage to increase fluid intake. 9. Encourage steam inhalation 10. Administer meds as ordered

secretions

airway.

6. >To facilitate breathing

7. >To expel the mucous

8. >To liquefy secretions

9. >To moisten secretions and alleviate congestion 10. >To reduce bronchospa

sm and mobilize secretion

ASSESSMENT

NURSING SCIENTIFIC DIAGNOSIS EXPLANATION

OBJECTIVES

INTERVENTIONS

RATIONALE

OUTCOMES

S= O= the patient may manifest:

Activity intolerance r/t general weakness

Due to the disease condition, the patient lost te energy reserve and has increased need to adapt to the pain of angina. Because of that she has limited movement. The inability to perform activities of daily living is also due to fatigue.

Short term:After 4 hours of nursing interventions and health teachings, the patient will be able to use identified techniques to enhance activity intolerance.Long term:After 2-4 days of nursing interventions, the patient will be able to participate willingly in necessary activities.

> monitor and record vital signs> teach method to increase activity level> plan care with rest periods between activities> provide positive atmosphere> assist with activities > promote comfort measures > encourage participation and diversion of activities

> for baseline data> to conserve energy> to reduce fatigue> to minimize frustrations> to protect from injury > to reduce pain > to minimize pain

Short term:The patient shall have identified and used techniques to enhance activity intolerance.Long term:The patient shall have participated willingly in necessary activities.

ASSESSMENT

NURSING DIAGNOSI S Fatigue

SCIENTIFIC EXPLANATI ON Fatigue is a overwhelming sense of exhaustion resulting to decreased capacity to perform activities at the usual level. This is due to the patients poor physical condition brought about by the disease condition.

OBJECTIVES

INTERVENTIONS

RATIONALE

OUTCOMES

S= O= the patient may manifest:> verbalization of overwhelming lack of energy;>compromi sed libido;>lethargic or listless > drowsiness > disinterest in surroundings >decreased performance >weight gain

Short term:After 2 hours of nursing interventions, the patient will be able to verbalize understanding of condition and causative factors.Long term:After 3 days of nursing interventions, the patient will be able to perform adls and participate in desired activities/level of activity.

> monitor vital signs>determine ability to participate in activities/level of mobility.>establish realistic activity goals with client>plan care to allow individually adequate rest periods, schedule activities for periods when client has the most energy>provide environment conducive >give medication as doctors ordered

> to provide baseline data>to enhances commitment to promoting optimal outcomes>to maximize participation>to encourage patients cooperation> to maintain/increase strength and muscle tone and to enhance sense of well-being. >to lessen fatigue

Short term:The patient shall have verbalized understanding of condition and causative factors.Long term:The patient shall have performed adls and participate in desired activities/level o

ASSESSMENT NURSINGDIAGNOS IS S> O>the patient manifested >fever of 38.4C >presence of adventitious sounds in both lung field. >productive cough >skin pale in color >restlessness -The patient may manifest>bo dy malaise >activity intolerance >decrease oxygen level Risk for infection (spread) related to inadequate secondary defenses(decrease hemoglobin, hematocrit and immunosuppressio n)

OBJECTIVES Short term:After 6 hours of nursinginterventionst he patients S.O will verbalize her understanding of individual causative/risk factors and demonstrate lifestyle changes to prevent further infection. Long term:After 1-2 days of nursinginterventionst he patient will be free from possiblespread of infection.

INTERVENTIO NS 1. Monitor v/s closely, especially during initiation of therapy.2. Assess depth/rate of respiration and chest movement.3. Instruct the S.O concerning about the disposition of secretions and report changes in color, amount and odor of secretions.4. Encourage good hand washing techniques. 5. Encourage adequate rest. 6. Stress the importance of increasing the childs nutritional

RATIONALE 1. To know potential fatal complication that may occur.2.Tachypne a, shallow respiration, and asymmetric chest movement are frequently presented because of discomfort of the moving chest wall and/or fluid in the lungs.3. To promote safety disposal of secretions and to assess for the resolution ofpneumonia or development of secondary infection.4. To reduce spread or acquisition of infection.

EXPECTED OUTCOME Short term:The patients S.O shall have verbalized her understanding of individual causative/risk factors and demonstrate lifestyle changes to prevent further infection. Lo ng term: The patient shall have been free from possiblespread of infection.

intake. 7. Encourage the mother to keep an eye to the baby and observe anything that the baby is putting in his mouth. 8. Administer antimicrobials as ordered.

5. To enhance fast recovery and regain strength. 6. A good nutritional intake can strengthen body immune defense. 7. To prevent entry of microbes. 8. To combat microbial pneumonias.

Risk for Aspiration related to increased mucous secretions