ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective Impaired gas After 1 hour of >Monitor RR,depth and effort “Goals met”
“Nahihirapan exchange related nursing including of accessory muscles The client is improved ventilation from
huminga ang anak to ventilation intervention the ,nasal flaring and abnormal
ko” perfusion client will breathing patterns P-145
imbalance improve
Objective ventilation >Auscultate every breath RR-22
-Restlessness sounds every 1-2 hours
-Irritability
-Tachycardia- >Monitor the clients behavior
P 181 for the onset of restlessness
-Cyanosis
-Diaphoresis >Observe for cyanosis of the
-Nasal Flaring skin especially note the color,
-Tachypnea RR-41 tongue and oral mucus
-Barrel chest membrane
-Wheezing on
expiration >Position the client in Semi
fowlers with an upright
position at 45 degree if
possible
>Administer bronchodilator as
ordered by the doctor
 ASSESSMENT DIAGNOSIS PLANNING NURSING EVALUATION
INTERVENTIONS
Subjective: Hypertermia After 30 mins. of >Identified underlying factors “Goal Met”
“Opo nilalagnat related to nursing that may cause alterations of
anak ko. Mainit po increase intervention the body temperature After 30 mins on effective nursing
cia” as verbalized metabolic rate client will >Monitored temperature every interventions the client was able to
by the mother ( illness) maintain core 30 minutes. maintain core temperature within
temperature >Monitored pulse rate and normal range of 37.5.
within normal respiratory rate Goal met
Objective: range of 37.5 Latest temp: 37.2
>Provided surface cooling
 Flushed skin from 38.1 such as TSB and removing of
 Warm to extra clothing.
touch
>Promoted rest and comfort
 Temperatur providing bed rest
e of 38.2
>Encouraged increase in fluid
 Respiratory intake.
rate of 27
 Pulse rate of
125 Dependent function:
>Administered paracetamol as
ordered.