Assessment Nursing Diagnosis Plan Intervention Rationale Evaluation

 Increase in Ineffective Breathing SHORT TERM 1. Establish 1. To gain SHORT TERM

respiratory rate of 31 Pattern: Inspiration rapport with patient’s Client shall
and/or expiration that After 2-3 hours of
cpm Shortness of patient trust and verbalize
does not provide nursing
breath (orthopnea) 2. Instruct cooperatio understanding
adequate ventilation. intervention,
Dyspnea Use of patient to n 2. and
patient will be
accessory muscles in increase oral Increased demonstrate
able to verbalize
breathing Altered fluid intake mucus and proper deep
understanding
chest excursion Nasal to 8-10 sputum breathing
and demonstrate
Flaring Increased glasses secretions technique to
proper deep
anterior posterior 3. Instruct can lead to facilitate
breathing
diameter patient to do dehydratio proper
technique to
deep n; oxygenation
facilitate proper
breathing increased to alleviate
oxygenation to
exercise after water hyperventilati
alleviate
demonstratin intake can on
hyperventilation
g proper help
technique dissolve
LONG TERM
4. Keep secretions LONGTERM
After 2-3 days of
environment 3. Deep Patient shall
nursing
allergen free breathing be free of
intervention,
(dust, feather exercise cyanosis and
patient will be
pillows, increases establish
free of cyanosis
smoke, oxygen normal
and establish
pollen) intake and breathing
normal breathing
5. Take and can help pattern
pattern
VS 6. Suction alleviate
naso, dyspnea 4.
tracheal/oral Presence
PRN may trigger
7. Educate allergic
proper hand response
washing that may
8. Position cause
the patient in further
semi fowler’s increase in
position 9. mucus
Encourage secretion 5.
patient to eat To get
nutritious baseline
foods such data 6.
as green These may
leafy compromis
vegetables e airway. A
and lean distended
meat 10. abdomen
Review can
client’s chest interfere
x-ray for with
severity of normal
acute/ diaphragm
chronic expansion
conditions 7. To
increase
feeling of
comfort 8.
To enable
the body
to
recuperate
and repair
9. To
prevent
infections
such as
nosocomial
infections
10. To
prevent
allergic
reactions
that can
cause
respiratory
distres
Assessment Nursing Diagnosis Plan Intervention Rationale Evaluation

With Short Term: After 3-4 1. Establish 1. To gain the Short Term:
unproductive Ineffective Airway hours of nursing rapport to trust and After 3-4
Clearance. Inability
cough With interventions, the patient and SO cooperation hours of
to clear secretions or
wheezes and obstructions from the patient’s respiration 2. Assess 2. To know nursing
crackles respiratory tract to will improve and patient’s and intervention
auscultated on maintain a clear difficulty of condition determine s, the
left lower airway. breathing will be 3. Monitor and patient’s patient’s
lungfield. relieved. record V/S needs 3. To respiration
Presence of 4. Auscultate establish base shall have
clear watery Long Term: After 3 – lung fields, line data improved
discharge from 4 days of nursing noting areas of 4. To identify and
her nose interventions, the decreased/abse areas of difficulty of
Restlessness patient will maintain nt airflow and consolidation breathing
Irritability a patent airway. adventitious and shall have
breath sounds determine been
5. Assist patient possible relieved.
to change bronchospas
position every m or Long Term:
30 minutes 6. obstruction. After 3 – 4
Elevate head of 5. To mobilize days of
bed and align secretions 6. nursing
head in the To facilitate intervention
middle breathing s, the
7. Provide 7. To expel patient will
health teachings the mucous 8. have been
regarding To liquefy able to
effective secretions maintain a
coughing and 9. To patent
deep breathing moisten airway.
exercise. secretions
8. Encourage to and alleviate
increase fluid congestion
intake. 10. To reduce
9. Encourage bronchospas
steam inhalation m and
10. Administer mobilize
meds as ordered secretion
Assessment Nursing Diagnosis Plan Intervention Rationale Evaluation

Fever of 38.4ºC  Risk for [Spread] Short term:After 1. Monitor v/s 1. To know Short term:The
Presence of of Infection: at 6 hours of closely, potential fatal patient’s S.O
increased risk for
adventitious nursing especially during complication shall have
being invaded by
sounds in both pathogenic interventions the initiation of that may occur. verbalized her
lung field. organisms. patient’s S.O will therapy. 2. 2. Tachypnea, understanding
Productive verbalize her Assess shallow of individual
cough Skin pale understanding depth/rate of respiration, and causative/risk
in color of individual respiration and asymmetric factors and
Restlessness causative/risk chest chest movement demonstrate
Body malaise factors and movement. 3. are frequently lifestyle changes
Activity demonstrate Instruct the S.O presented to prevent
intolerance lifestyle changes concerning because of further infection.
Decrease to prevent about the discomfort of Long term: The
oxygen level further infection. disposition of the moving patient shall
Long term: After secretions and chest wall have been free
1-2 days of report changes and/or fluid in from possible
nursing in color, amount the lungs. 3. To spread of
interventions the and odor of promote safety infection.
patient will be secretions. 4. disposal of
free from Encourage good secretions and
possible spread hand washing to assess for the
of infection. techniques. 5. resolution of
Encourage pneumonia or
adequate rest. 6. development of
 Stress the secondary
importance of infection. 4. To
increasing the reduce spread or
childs nutritional acquisition of
intake. 7. infection. 5. To
Encourage the enhance fast
mother to keep recovery and
an eye to the regain strength.
baby and 6. A good
observe nutritional
anything that intake can
the baby is strengthen body
putting in his immune
mouth. 8. defense. 7. To
Administer prevent entry of
antimicrobials as microbes. 8. To
ordered. combat
microbial
pneumonias.

https://accpjournals.onlinelibrary.wiley.com/doi/abs/10.1002/j.1875-9114.1995.tb04345.x

https://www.amazon.com/Nurses-Pocket-Guide-Prioritized-Interventions/dp/0803644752/ref=as_li_ss_tl?ie=UTF8&linkCode=sl1&tag=nl-ncps-
20&linkId=27474e59ad2bf45be52b2c963b3a14d4&language=en_US

https://www.healio.com/nursing/journals/rgn/2011-4-4-2/%7B4a97ea17-a9a7-44a1-a6ef-7765f4987823%7D/nursing-diagnoses-interventions-
and-patient-outcomes-for-hospitalized-older-adults-with-pneumonia
Assessment Nursing Diagnosis Plan Intervention Rationale Evaluation

Flushed Skin Short term: After 1. Establish 1. To gain trust Short term: After
 Skin Warm to Hyperthermia: 4° of NI, the pt’s Rapport 2. and have a 4° of NI, the pt’s
Body temperature
Touch temperature will Monitor VS q 4°. nurse patient temperature
elevated above
 Temperature normal range. drop from 38.4 3. Provide TSB as relationship 2. shall drop from
Higher than °C to 37 °C Long a measure. 4. To establish 38.4 °C to 37.4
37.6C term: After 2-3 Instruct SO to baseline data of or lower °C.
 Rales days of NI, the provide with the pt’s 3. To Long term: After
 Dehydration patient will be loose clothing. lower pt’s 2-3 days of NI,
 Irritability free from 5. Assess skin temperature 4. the patient shall
hyperthermia. temperature and To release heat be free from
color. 6. Monitor and to provide hyperthermia.
WBC count. 7. comfort 5.
Encourage fluid Warm, dry,
intake orally or flushed skin may
intravenously as indicate a fever.
ordered. 8. 6. eucocytes
Measure intake indicate an
and output. inflammatory
and infectious
process
 presence. 7.
Replaces fluid
lost by
insensible loss
and perspiration.
8. Determine
fluid balance
and need to
increase fluid
intake.

Assessment Nursing Diagnosis Plan Intervention Rationale Evaluation

Impaired Gas Short term:After 1. Monitor vital 1. To establish Short term:The

restlessness Exchange: excess 6 hours of signs and assess baseline data. 2. patient shall
irritability nasal or deficit in
flaring oxygenation nursing patient’s Determine have
diaphoresis and/or carbon interventions the conditions. 2. adequacy of gas demonstrated
dioxide
tachycardia patient will Auscultate lungs exchange and ease in
elimination at the
dyspnea alveolar-capillary demonstrate for crackles , detect areas of breathing. Long
membrane. ease in consolidation consolidation term: The
breathing. Long and pleural and pleural patient’s S.O will
term: After 2-3 friction rub. 3. friction rub. 3. verbalized
days of nursing Assess LOC, This signs may understanding
interventions the distress and indicate hypoxia. of the causative
patient’s S.O will irritability. 4. 4. Determine factors that
verbalize Observe skin circulatory could aggravate
understanding color and adequacy, which the condition
of the causative capillary refill. 5. is necessary for and appropriate
factors that Encourage rest. gas exchange to factors that
could aggravate 6. Encourage tissues. 5. Rest could help the
the condition elevated HOB. 7. prevents tissue patient relive
and appropriate Perform chest oxygen demand from gas
factors that physiotherapy and enhances exchange
could help the after tissue oxygen impairment.
patient relive nebulization. 8. perfusion. 6. To
from gas Administer facilitate lung
exchange oxygen as expansion to
impairment. ordered. enhance
breathing. 7. To
dislodge the
secretions, for
easy
 expectoration 8.
Improves
gasexchange
decrease work
of breathing.

1. Ineffective Airway Clearance

2. Impaired Gas Exchange
3. Ineffective Breathing Pattern
4. Risk for Infection
5. Hyperthermia

https://accpjournals.onlinelibrary.wiley.com/doi/abs/10.1002/j.1875-9114.1995.tb04345.x

https://www.amazon.com/Nurses-Pocket-Guide-Prioritized-Interventions/dp/0803644752/ref=as_li_ss_tl?ie=UTF8&linkCode=sl1&tag=nl-ncps-
20&linkId=27474e59ad2bf45be52b2c963b3a14d4&language=en_US

https://www.healio.com/nursing/journals/rgn/2011-4-4-2/%7B4a97ea17-a9a7-44a1-a6ef-7765f4987823%7D/nursing-diagnoses-interventions-
and-patient-outcomes-for-hospitalized-older-adults-with-pneumonia
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diagnoses, interventions, and patient outcomes for hospitalized older adults with pneumonia. Research in
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 Yoshino, A., Ebihara, T., Ebihara, S., Fuji, H., & Sasaki, H. (2001). Daily oral care and risk factors for pneumonia
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