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Ligaya Millare

51 F
CASE: Community Acquired Pneumonia, Moderate risk
ASSESSMENT NURSING DIAGNOSIS INFERENCE OR SCIENTIFIC PLANNING/ NURSING RATIONALE EVALUATION
BACKGROUND OBJECTIVES INTERVENTIONS
Subjective: marigatan nak nga Impaired gas exchange r/t Pneumonia is an excess of fluid After 8 hours of Independent: After 8 hours of
umanges no sagpaminsan ngem collection of secretions in the lungs from an nursing assess Manifestation of nursing
toy uyek ko ti nakaro nakkong affecting oxygen exchange inflammatory process. The interventions, the respiratory rate, respiratory interventions, the
as verbalized by the patient. across alveolar membrane. inflammatory may be triggered patient will depth and ease. distress. patient achieved
by many infectious organisms achieve timely Monitor body High fever timely resolution
Use of accessory and by inhalation of irritating resolution of temperature. greatly of current
muscle agents. Pneumonia can be current infection Elevate head of increased infections without
Dyspnea classified into either Nosocomial without bed and change metabolic complications.
Tachypnea or the hospital acquired or the complications. position if demands and
V/s taken as follows: Community-acquired necessary. oxygen
T- 36.4c Pneumonia. Institute consumption.
PR- 80 Bpm isolation Promotes
RR-20 Cpm precaution. expectoration
BP-90/60 MmHg Suction as clearing or
needed. infection.
Assist with Isolation
nebulizer technique may
treatments. be desired to
Monitor prevent spread
effectiveness of and protect the
microbial patient from
therapy other infections.
Collaborative: To facilitates
Administer liquefaction and
antimicrobials removal of
as prescribed. secretions.
ASSESSMENT NURSING INFERENCE OR PLANNING/ NURSING RATIONALE EVALUATION
DIAGNOSIS SCIENTIFIC OBJECTIVES INTERVENTIONS
BACKGROUND
Subjective: no dadduma keh nagrigat Ineffective Pneumonia is an After 4 hours of Independent: GOAL MET:
ti aguyek kasla adda bimmara toy airway clearance excess of fluid in the nursing assess Manifestation of After 4 hours of nursing
karabukob ko nakkong related to lungs from an interventions, the respiratory rate, respiratory interventions, the patient airway is
increased inflammatory process. patient airway depth and ease. distress. clear with no symptoms or episodes
Objectives: production of The inflammatory will be clear and Elevate head of Promotes of dyspnea.
Dysnea secretions. may be triggered by can able to breath bed and change expectoration
v/s taken as follows: many infectious normally. position if clearing or
T- 36.4c organisms and by necessary. infection.
PR- 80 Bpm inhalation of irritating Suction as To facilitates
RR-20 Cpm agents. Pneumonia needed. liquefaction and
BP-90/60 MmHg can be classified into Assist with removal of
either Nosocomial or nebulizer secretions.
the hospital acquired treatments.
or the Community- Teach chest
acquired physiotherapy
Pneumonia. or back tapping
techniques after
nebulization.
ASSESSMENT NURSING INFERENCE OR PLANNING/ NURSING RATIONALE EVALUATION
DIAGNOSIS SCIENTIFIC OBJECTIVES INTERVENTIONS
BACKGROUND
Subjective: nagsakit ti barukong ko Acute pain Angina can result After 8 hours of Assess for v/s To differentiate Goal met:
nagdagsen ramaramen na pay toy related to severe from any condition in nursing and symptoms angina pain
tengned ko kada toyan ko nakkong as coughing. which there is a intervention the of pain such as from related to After 8 hours of nursing
verbalized by the patient. decrease in oxygen patient will: facial grimace other causes. intervention the patient is:
delivery by the Remain and To monitor the free from pain
Objective: coronary arteries. free tachycardia. effectiveness of Maintain stable vital signs
Tachycardia Angina can result from Use a pain medications Relaxed body posture
Dyspnea from aortic stenosis, pain rating scale to given for pain
Guarding behavior mitral stenosis, Maintain assess the relief.
T- 36.4c arrhythmias or even stable patients To provide
PR- 80 Bpm Pneumonia. vital perception of optimal
RR-20 Cpm signs pain severity. oxygenations.
BP-90/60 MmHg Maintain Place and assist To facilitate
relaxed on bed rest in a secretions.
body semi to high
posture fowlers
position.
Instructed deep
breathing and
proper
positioning.
Juliana Raposas
69 F
CASE: Moderate Pleural effusion
ASSESSMENT NURSING INFERENCE OR PLANNING/ NURSING RATIONALE EVALUATION
DIAGNOSIS SCIENTIFIC OBJECTIVES INTERVENTIONS
BACKGROUND
Subjective: adda ti danom sa bara na Ineffective Pleural effusion is the After 8 hours of Check out Respiratory GOAL UNMET.
nakkongas verbalized by the breathing pattern accumulation of fluid nursing intervention respiratory distress may Patient died @ 10:45 Am
significant other. related to in the pleural space or the patient will be function and occur and
inflammatory in the lungs. able: changes in vital changes of vital
Objective: process as To breath signs. sign result of
Tachycardia evidenced by with using Assist patient physiological
Dyspnea dyspnea and use of accessory with splinting stress and pain.
Use of accessory muscle of accessory muscle painful area Supporting
T- 36.8c muscle. Establish a when chest and
PR- 860 Bpm normal/ coughing, deep abdominal
RR-20 Cpm effective breathing. muscles make
BP-120/800 MmHg respiratory Maintain coughing more
Pa02- 91% pattern. position of effective and
comfort, less traumatic
usually with Promotes
head of bed maximal
elevated. inspiration.
Assist in Enhances lung
positioning to expansion.
affected side
and encourage
to sit as much
as possible.
Maintain
proper
ventilation
Encourage
proper
coughing
exercise.
ASSESSMENT NURSING INFERENCE OR PLANNING/ NURSING RATIONALE EVALUATION
DIAGNOSIS SCIENTIFIC OBJECTIVES INTERVENTIONS
BACKGROUND
Subjective: nagrigatak nga Ineffective Pleural effusion is the After 8 hours of Determine the Help nurse on GOAL UNMET.
makaanges as verbalized by the health accumulation of fluid nursing intervention client health the complete Patient died @ 10:45 Am
patient. maintenance in the pleural space or the patient will be care regimen. prescribed
Objectives: in the lungs. able: treatment
Irritability To increase regimen for the
Dizziness compliance client.
Dyspnea to the
tachycardia medical
T- 36.8c treatment
PR- 860 Bpm regimen
RR-20 Cpm Gradually
BP-120/80 MmHg meats the
Pa02- 91% goals for
health care
maintenance
Improve
clients
physical,
mental and
social well-
being
ASSESSMENT NURSING INFERENCE OR PLANNING/ NURSING RATIONALE EVALUATION
DIAGNOSIS SCIENTIFIC OBJECTIVES INTERVENTIONS
BACKGROUND
Objective: Anxiety related Anxiety disorders are After 8 hours of Recognize To decrease GOAL MET.
Tachycardia to health status the most common nursing intervention awareness of level of After 8 hours of nursing
Dyspnea mental status in the the patient will be patients irritability and intervention patient decreases her
Dizziness U.S. it affects the able: anxiety dizziness level of anxiety.
Irritability poor the rich, the Identifies Interact with
T- 36.8c young and anyone strategies to patient in
PR- 860 Bpm from all walks of life reduce of peaceful
RR-20 Cpm can suffer from anxiety. manner
BP-120/800 MmHg anxiety disorder. Patient Accept
Pa02- 91% describes patients
own anxiety defenses, do
and coping not care, argue
patterns. or debate.
Patient
demonstrates
improved
concentration
and accuracy
of thoughts.