ASSESSMENT DIAGNOSIS Problem PLANNING NURSING RATIONALE EVALUATION

Analysis INTERVENTION

Subjective: Hyperthermia r/t Fever is an After 1hour of Independent:

“Nilalagnat ako”, to infection in the elevated nursing  Monitor V/S  To have a  After 1 hour
as verbalized by lungs as evidence body intervention the specially body baseline data nursing
the patient. by the ff: temperatur client will have temperature for intervention
e that may a decrease comparison. the client has a
Objective:  Cough and due to body  Apply TSB  To evaporate body
V/S: Dyspnea infection in temperature of the heat on the temperature of
T: 39.9 lungs 39.C from body 39.2.C from
PR : 93  Dry skin 39.9.C  Provide rest and  It can 39.9.C as
comfort contribute evidence by
 Flush patient to have the ff:
appearance normal body
 Warm to temperature  Showed slight
touch  Provide quiet  To have flush
environment comfortable appearance
rest
 Provide  For the  Still warm to
ventilation conduction of touch
the heat on
body  Goal partially
 Increase fluid  To lessen the met
intake heat on the
body
Dependent:

 Administer  It can help the

Paracetamol patient have a
500mg tablet as normal body
ordered by the temperature
doctor faster
 ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTION

Subjective: Ineffective Airway After 4 hours of Independent:

“Nahihirapan akong Clearance r/t intervention the  Note respiratory  To have a  After 4 hours of
huminga”, as verbalized increase sputum patient airway will rate. baseline data for intervention the
by the patient. production in be able to display comparison. patient’s airway
response to better airway as will display
Objective: respiratory manifested by  Position the  Promotes better patent airway
RR : 29 infection as clear breath sounds patient semi/high lung expansion with clear breath
BP : 120/70 evidence by and absence of fowler position and improved sounds, decrease
abnormal breath dyspnea to facilitate better gas exchange. in restlessness
 Crackling sounds breathing and absence of
breath sound dyspnea as
 Dyspnea  Encourage  To improve evidence by:
 Restlessness frequent position breathing pattern
 Productive changes and  V/S:
cough deep breathing RR: 23
or coughing BP: 120/70
exercise.(purse
lip exercise)  Goal partially
met.
 Encourage  To remove
patient to sputum and
expectorate mucous plug
secreations

Dependent:  An antitussive
 Administer drug that act as a
levopront as cough
ordered by the suppressant.
doctor.
 Administer  It is used to
combivent as treat or prevent
ordered by the wheezing and
doctor. shortness of
breath caused
by ongoing
breathing
problems

Collaborative:  It is favorable
Assist in route in
performing administering
nebulization of the bronchodilators
patient and aids in
: expectorating
secreations
 ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTION

Subjective: Actvity intolerance After 4 hours of Independent:

Subjective: “Hindi related to exhaustion nursing interventions,  After 4 hours of
ako makatulog dahil associated with the patient will Provide a quiet  Reduces stress and intervention the
sa ubo ko” as interruption in usual demonstrate a environment and excess stimulation, patient will free
verbalized by the sleep pattern because measurable increase limit visitors during promoting rest from signs of
patient. of discomfort, in tolerance in activity acute phase. distress and
excessive coughing with absence of respirations are
Objective: and dyspnea dyspnea and of normal rate.
V/S taken as follows: excessive fatigue Elevate head and  These measures
T: 37.7 encourage frequent promotes maximal
P: 90 position changes, inspiration,  V/S:
R: 29 deep breathing and enhance T: 38.6
BP: 110/80 effective coughing. expectoration of PR: 78
secretions to RR: 23
 Fatigue. improve BP: 120/70
 Dyspnea ventilation.
 Goal partially
met.
Encourage adequate  Facilitates healing
rest balanced with process and
moderate activity. enhances natural
Promote adequate resistance
nutritional intake

Dependent:  An antitussive
 Administer drug that act as a
levopront as cough
ordered by the suppressant.
doctor.
 Administer  It is used to treat
combivent as or prevent
ordered by the wheezing and
doctor. shortness of
breath caused
by ongoing
breathing
problems.
Nursing prioritization

Nursing problem Cues Justification

 Ineffective Airway Clearance  Crackling breath sound We choose ineffective airway clearance as our
 Dyspnea nursing priority because there is a cracking
 Restlessness breath sound, dyspnea, restlessness and
 Productive cough productive cough tha implies decrease
production of oxygen.
 Fever  T: 39.9
 Flush appearance We choose fever as our 2nd nursing priority
 Warm to touch because there is elevated body heat, flush
appearance and warm to touch that implies
infection in the system of the patient
 Cough  Fatigue
 Dyspnea We choose fever as our 3rd nursing priority
because there are signs of fatigue and
dyspnea that unable the patient to do activity
due to persisting cough