ASSESSMENT NURSING OBJECTIV NURSING RATIONALE EXPECTE

DIAGNOSIS ES INTERVENTIO D
NS OUTCOM
ES

S> Ø Ineffective Short Term: >Establish rapport >To gain the Short Term:
airway to patientand SO trust and
clearancerelat cooperation
ed to presence
O> Patientmanifes of secretions After 3-4 After 3-4
ted the ff: secondary hours hours
topneumonia. ofnursing >To know and ofnursing
interventions, >Assess patient’s determinepatien intervention
the patient’s condition t’s needs s,
- with respiration the patient’s
unproductive will improve respiration
cough and difficulty shall have
of breathing >To establish improved
-with wheezes and base line data and
will be >Monitor and
crackles
relieved. record V/S difficulty of
auscultated on left
breathing
lower lungfield.
>To identify shall have
- presence of clear been
Long Term: >Auscultate lung areas of
watery discharge consolidation relieved.
from her nose fields, noting and determine
areas of possible
After 3 – 4 decreased/absent bronchospasm
days airflow and or obstruction.
> Patient may ofnursing adventitious
Long Term:
manifest the ff: interventions, breath sounds
the patientwil
- restlessness >To mobilize
l maintain a
patent airway >Assist patient to secretions After 3 – 4
- irritability
. days
change positionev
ofnursing
ery 30 minutes
intervention
s,
>To facilitate the patientw
>Elevate head of breathing ill have been
bed and align head able to
in the middle maintain a
patent airwa
y.

>Provide health
teachings
regarding
effective coughing >To expel the
and deep mucous
breathing exercise.

>Encourage to
increase
fluidintake.

>Encourage steam
inhalation
>To liquefy
secretions

>Administer meds
>To moisten
as ordered
secretions and
alleviate
congestion

>To reduce
bronchospasm
and mobilize
secretion