Assessment Nursing Scientific Objectives Interventions Rationale Expected

Diagnosis Explanation Outcome

Subjective: Ineffective Normally the Short term goal: Independent: Independent: After 1-2 hours of
Ø airway lungs are free After 1-2 hours of -Monitor -To indicate nursing
clearance from nursing respiration and respiratory intervention, the
Objective: related to secretions. intervention, the breath sounds distress and/or patient shall have
The patient retained Pneumonia patient will be accumulation of been
may secretions bacteria are able to secretions demonstrated
manifest: as invading the demonstrate behaviors to
- changes in evidenced lung behaviors to -Encouraged -To lessen improve or
respiratory by parenchyma improve or hydration at secretions maintain clear
rate and unproductive thus, maintain clear least 8 glasses airway such as
depth cough producing airway such as of water following
- abnormal secondary to inflammatory following everyday pharmacologic
breath pneumonia process. And pharmacologic regimen
sounds these regimen -Position head -To open or
- use of responses appropriate for maintain open After 1 day of
accessory leading to Long term goal: condition such airway in at rest nursing
muscles filling of the After 1 day of as fowler’s or compromised interventions, the
- dyspnea alveolar sacs nursing position individual. patient shall have
and SOB with exudates interventions, the been maintained
-non- leading to patient will be -Encourage -To limit fatigue airway
productive consolidation. able to maintain adequate rest clearance/patency
cough The airway is airway periods.
-increased narrowed thus clearance/patency
production of wheezes is Dependent Dependent:
viscous being heard. - Administer -To promote
secretions medications pharmacologic
- RR of 50 such as regimen
bronchodilators
 Collaborative Collaborative:
-Assist with -To maintain
procedure such clear open
as airway
administering
02

Assessment Nursing Scientific Objectives Interventions Rationale Expected

Diagnosis Explanation Outcome
Subjective: Ø Activity Activity Short term Independent: Independent: After 1-2 hours of
intolerance intolerance is a goal: -Provide a quiet -Reduces stress nursing
Objective: related to state in which After 1-2 environment and and excess intervention, the
The patient exhaustion, an individual hours of limit visitors stimulation, patient shall have
may discomfort, has insufficient nursing during acute promoting rest been
manifest: dyspnea physiologic or intervention, phase as demonstrated an
- weak in excessive psychological the patient indicated. increase in
appearance coughing, energy to will be able to Encourage use of activity level as
- shallow and endure or demonstrate stress manifested by
respirations weakness complete an increase management and gradual tolerance
-RR of 48 required or in activity diversional to active range of
- use of desired daily level as activities as motion
accessory activities. manifested appropriate.
muscles Activity by gradual After 1-2 days of
Intolerance is tolerance to nursing
- dyspnea related to active range interventions, the
and pallor decreased of motion -Assist patient to -Patient may be patient shall have
-slow oxygen levels assume comfortable with increased and
movements for metabolic Long term comfortable head of bed achieved desired
-needs demands. For goal: After 1 position for rest elevated, sleeping activity level,
assistance in pneumonia, day of and sleep. in a chair, or progressively
changing energy reserves nursing leaning forward on without
position are also interventions, -Position head over bed table with intolerance
depleted due to the patient appropriate for pillow support. symptoms such
insufficient will be able to condition such as as respiratory
intake of food increase and fowler’s position compromise
during periods achieve -To limit fatigue
of dyspnea. desired -Encourage
activity level, adequate rest
progressively periods.
without
intolerance
symptoms
such as
respiratory
compromise