ASSESSMENT BACKGROUND NURSING OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS INTERVENTION OUTCOME

Subjective: Pneumonia is an Short Term: Independent: Manifestations Short term:
“Nahihirapan excess fluid in the Impaired gas Assess respirations: of respiratory
siya minsan lungs resulting exchange After six hours note quality, rate, distress After six hours of
huminga dahil sa related to of nursing rhythm, depth, use of are dependent on appropriate
from an
ubo niya” inflammation intervention, accessory muscles indicative of the nursing
verbalized by the inflammatory of airways the patient degree of lung intervention, the
process. and ease.
grandmother condition will involvement and patient will
lighten, and underlying minimize
Monitor body
Objective: Inflammation minimal general health secretion, and
temperature
Patient looks triggered by many formation of status becomes active.
irritable infectious agents. secretion will
Elevate head and
occur encourage frequent High fever Long Term:
Community-
Presence of position changes, (common in
productive cough acquired Long Term: bacterial After one week of
deep breathing, and
pneumonia (CAP) pneumonia) appropriate
effective coughing.
Vital sign: refers to the acute After one week greatly increases nursing
infection of the of nursing Dependent: metabolic intervention, the
PR:125 RR: 30 lung parenchyma intervention Administer demands patient will enable
in non- patient will be Cefuroxime every 8
to exchange
Temp: 36.6 free from These measures oxygen normally
hospitalized hours
secretion promote and free from
patients; it is enabling maximum chest secretions.
characterized by condition of Interdependent: expansion,
Collaborate to
the development oxygen mobilize
respiratory therapist
of fever and/or exchange secretions and
in administering
respiratory normally. improve
Pulmodual in
nebulization. ventilation.
symptoms, as
well as the
presence of
pulmonary
infiltrates.

Client: MORFE, A. 2 years old | Care Plan by: BON HAROLD BACOL BSN 2 | Date Initiated: March 6. 2020