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Patient’s name: F.R.

Cues/ Clues
Subjective:
As verbalized by the
patient:
“Nahihirapan ako
huminga kapag
nakahiga”
“Masakit yung dibdib ko
kapag umuubo”
“Di ako makatulog dahil
sa ubo ko tuwing gabi”
Objective:
 (+) non
productive cough
 Difficulty in
breathing
 Irritability
 Restlessness
 Chest pain upon
coughing

Age: 55 years old

Nursing
Diagnosis

Inference

Impaired gas
exchange
related to
alveolar-capillary
membrane
changes
secondary to
pneumonia

Excess or deficit
in oxygenation
and/ or carbon
dioxide
elimination at the
alveolar-capillary
membrane
(NANDA page
421)

Goal and
Objectives

Medical Diagnosis: Community-Acquired Pneumonia

Nursing
Intervention

Rationale

Long-term goal:
Independent:
Independent:
After 3 days of
 Elevate the head
 For easy access
interventions, goals are
and help change the
of airway and
fully met as evidenced
position
of
the
client
proper breathing
by:
(semi fowler or high
 Verbalize
fowler’s position)
understanding
 Insist the client to
 To prevent
of causative
increase oral intake
dehydration and
factors and
and
check
the
IV
moisten the air
appropriate
respectively.
pathway
intervention

Auscultate
for

Adventitious
 Perform
any
breathe sounds
treatment
adventitious
can alter
regimen (deep
breathe sounds
respiratory
breathing
function
 Monitor the
exercise)
 To check if
client’s vital
 Maintain airway
patency
sign (heart rate
there’s a change
and respiratory
in the baseline
Short-term goal:
rate)
data
After 12 hours of
interventions, goals are Dependent:
Dependent:
fully met as evidenced
 Give Ceftriaxone
 To inhibits
by:
(Xtenda) 1mg IV
synthesis of
 Decrease
Q12
bacterial cell wall
irritability
Collaborative:
 Breathe without Collaborative:

Assist
the
client
on
 Evaluation is
difficulty
consultation with a
necessary to
 Have enough
radiologist for a
visualize the path
rest at night
chest x-ray report.
of airway

Evaluation
Long-term goal:
After 3 days of
interventions, goals are
fully met as evidenced
by:
 Verbalized
understanding of
causative factors
and appropriate
intervention
 Performed
treatment
regimen (deep
breathing
exercise)
 Maintained
airway patency
Short-term goal:
After 12 hours of
interventions, goals are
fully met as evidenced
by:
 Decreased
irritability
 Normal breathing

Absence of sleep
disturbance

goals are fully met as evidenced by:    Electrolytes and fluids are balanced Normal bowel sounds Semi-formed stools Short-term goal: After 12 hours of interventions. goals are fully met as evidenced by:  Decreased restlessness  Diminished muscle weakness  Normal urine output . step of acid production Collaborative:  To assess if there is any pathogens. goals are fully met as evidenced deficit and by: electrolyte  Decrease imbalances persist  Deficit in fluid restlessness or worsen. and electrolytes  Diminish muscle can cause severe Dependent: weakness dehydration that  Give Omeprazole 40mg  Normal urine can lead to death PO OD output Collaborative:  Assist the client on consultation with a medical technologist for Dependent:  It blocks the final a fecalysis report.R Cues/ Clues Subjective: As verbalized by the patient: “ Malambot yung dumi ko at kulay green” “Naka-apat na dumi na ako ngayong araw” “ Madalas ako mauhaw” Objective:        Watery stool Muscle Weakness Restlessness Increase urine output (+) Abdominal pain Hyperactive bowel sounds (+) Acute gastroenteritis Age: 55 years old Nursing Diagnosis Risk for electrolyte imbalance related to diarrhea secondary to acute gastroenteritis Inference At risk for change in serum electrolyte levels that may compromise health (NANDA Page 341) Goal and Objectives Medical Diagnosis: Community-Acquired Pneumonia Nursing Intervention Rationale Long-term goal: Independent: Independent: After 3 days of  Assess for sudden  Decreased in interventions. goals are weight loss weight results in fully met as evidenced deficit of fluid and  Administer fluid by: electrolytes and electrolyte  Electrolytes and  To provide what replacements if fluids are balance ordered is loss in the  Normal bowel body sounds  Assist client to  Semi-form stools select foods/fluids  Potassium is high in potassium essential for Short-term goal:  Consult physician balancing After 12 hours of if fluid volume electrolytes interventions. parasites and Evaluation Long-term goal: After 3 days of interventions.Patient’s name: F.

bacteria Patient’s name: F. Cues/ Clues Age: 55 years old Nursing Diagnosis Inference Goal and Objectives Medical Diagnosis: Community-Acquired Pneumonia Nursing Intervention Rationale Evaluation .R.

limited interruptions of sleep amount and quality due to external factors (NANDA Page 878) “Di ako makatulog ng maayos kasi ubo ako ng ubo” Objective:  Cough  Chest pain  Restlessness  Afternoon nap  Weakness  Yawning Patient’s name: F. goals are disturbance fully met as evidenced just before by: bedtime  Decrease  To promote  Administer restlessness longer period of medications  Decrease sleep and avoid that can weakness disturbances interfere with  Diminish cough sleep early in  Absence of the morning chest pain Dependent: Dependent:  Give aldactone early  To avoid in the morning disturbance of Collaborative: rest at night  Coordinate with Collaborative: other health  To provide a professional and quiet provide a quiet environment and environment promote sleep Age: 55 years old Inference Goal and Objectives Long-term goal: After 3 days of interventions. goals are intake of foods make you fully met as evidenced and fluids high hyperactive by: in caffeine  State of feeling  To provide long well and rested  Offer client an period of sleep  Diminish evening snack yawning that includes milk or cheese Short-term goal:  Encourage  To avoid sleep After 12 hours of client to urinate interventions. goals are fully met as evidenced by:  Decreased restlessness  Decreased weakness  Diminished cough  Absence of chest pain Medical Diagnosis: Community-Acquired Pneumonia Nursing Intervention Rationale Evaluation .R Cues/ Clues Nursing Diagnosis Long-term goal: Independent: Independent: After 3 days of  Discourage  Caffeine can interventions. goals are fully met as evidenced by:   Stated of feeling well and rested Absence of yawning Short-term goal: After 12 hours of interventions.Subjective: As verbalized by the patient: “ Di ako makatulog ng maayos sa gabi kasi sumasakit yung dibdib ko” Disturbed sleep pattern related to interruptions secondary to pnuemonia Time.

sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months (NANDA Page 658) Long-term goal: Independent: After 3 days of  Assess pain interventions. After 12 hours of interventions. Short-term goal: relaxation.Subjective: As verbalized by the client: “ Masakit yung dibdib ko kapag umuubo ako” Objective:  (+) Chest pain  Weakness  Restlessness  Irritability  (+) Non productive cough Acute pain related to cough secondary to pneumonia Unpleasant sensory and emotional experience arising from actual or potential tissue damage . goals are fully met as evidenced by:   Diminished pain Relaxed and increased activity appropriately Short-term goal: After 12 hours of interventions. goals are breathing fully met as evidenced exercise) by:  Diminish Dependent: weakness  Give Salbutamol  Diminish 1neb Q12 neb Restlessness  Absence of Collaborative: irritability  Coordinate with other health professional and provide a quiet environment Patient’s name: F.R Age: 55 years old Independent:  To assess if the pain is severe   To compared with base line data and check if there is abnormalities The convenient measure will interfere with pain and patient is more focus in relaxing Dependent:  For patency of airway Collaborative:  To provide relaxation and peaceful environment Medical Diagnosis: Community-Acquired Pneumonia Long-term goal: After 3 days of interventions. goals are fully met as evidenced by:  Diminished weakness  Diminished Restlessness  Absence of irritability . goals are level using pain fully met as evidenced scale by:  Monitor vital  Diminish pain signs  Relax and  Provide increase activity convenient appropriately measure (music therapy.

goals are bed fully met as evidenced by:  Encourage  Breath increase fluid comfortably intake  Diminish chest Dependent: pain  Salbutamol 1neb  Provide airway Q12 neb clearance Rationale Independent:  It indicates airway obstruction  The repiratory will increase if there is an obstruction Evaluation Long-term goal: After 3 days of interventions. and the alveoli effort. obstruction in depth.  Perform deep  Monitor pulse breathing oxygen exercise saturation level  Elevate the Short-term goal: After 12 hours of head of the interventions. goals are any breath fully met as evidenced sounds by:  Maintain  Monitor patency of respiratory airway patterns.Cues/ Clues Subjective: Nursing Diagnosis Ineffective airway As verbalized by the clearance client: related to exudate in the “Nahihirapan ako huminga alveoli kapag umuubo ako” secondary to pneumonia “Nahihirapan ako huminga kapag nakahiga ako” Objective:     (+) Non productive cough Restlessness Chest pain Difficulty in breathing Inference Inability to clear secretion or obstructions from the respiratory tract to maintain a clear airway (NANDA Page 85) Goal and Objectives Nursing Intervention Long-term goal: Independent: After 3 days of  Auscultate for interventions. goals are fully met as evidenced by:  Breathed comfortably  Diminished chest pain  Provided airway clearance . goals are fully met as evidenced by:       Decrease O2 saturation level indicate hypoxemia To promote lung expansion To hydrate and moisten the mucosa Dependent:  To moisten the mucosa Collaborative:   Assist the client on Collaborative: consultation with a  To assess if there medical technologist is any presence for a chest x-ray and of bacterial sputum test infection Maintained patency of airway Diminished obstruction in the alveoli Performed deep breathing exercise Short-term goal: After 12 hours of interventions.  Diminish including rate.