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  • Assessment Diagnosis Planning Interventions Evaluation Subjective Data: Long Term Short Term

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    Hajrah Dipantar
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    The patient presented with fever, headache, body pain, tachycardia, tachypnea, productive cough with purulent sputum and runny nose. The diagnosis was ineffective airway clearance related to pneumonia. The long term plan was to achieve return of ability to maintain patent airways and respiratory status baselines. The short term plan was to prevent further complications by providing patient education about disease process, prognosis and treatment.

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    The patient presented with fever, headache, body pain, tachycardia, tachypnea, productive cough with purulent sputum and runny nose. The diagnosis was ineffective airway clearance related to pneumonia. The long term plan was to achieve return of ability to maintain patent airways and respiratory status baselines. The short term plan was to prevent further complications by providing patient education about disease process, prognosis and treatment.

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    10 views1 page

    Assessment Diagnosis Planning Interventions Evaluation Subjective Data: Long Term Short Term

    Uploaded by

    Hajrah Dipantar
    The patient presented with fever, headache, body pain, tachycardia, tachypnea, productive cough with purulent sputum and runny nose. The diagnosis was ineffective airway clearance related to pneumonia. The long term plan was to achieve return of ability to maintain patent airways and respiratory status baselines. The short term plan was to prevent further complications by providing patient education about disease process, prognosis and treatment.

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    © All Rights Reserved
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    ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS EVALUATION

    Subjective Data: Ineffective Airway LONG SHORT ACTION RATIONALE


    - Fatigue Clearance related to TERM TERM
    - Headache pneumonia as
    - Body Pain manifested by fever, To achieve To prevent
    bradycardia, tachypnea, the return further
    Objective Data: productive cough with of and complications
    - T: 39.4c purulent sputum and ability to by providing
    - RR:27 bpm runny nose maintain patient
    - PR:55 bpm patent information
    - Productive Cough airways about
    - Runny Nose and disease
    - Production of respiratory process,
    Purulent Sputum status prognosis
    - Restlessness baselines and
    of the treatment
    patient

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