ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Respiratory Tract STG (Short Term 1. Monitor VS 1. To assess STG (Short Term
“nagalisod siya ug Infection Goal) every 4 hrs. baseline data. Goal)
hinga gamay sir
tungod sa iyahang After the end of the 2. Encourage patient 2. Promotes After the end of the
ubo”, as verbalized shift, the client will to position in semi- maximal lung shift, the client had
by the patient’s be able to cough fowler’s position. function. been able to cough
mother. effectively and clear effectively and clear
own secretions. 3. Turn patient 3. Repositioning own secretions.
every 2 hrs. promotes drainage Goal was met.
of pulmonary
Objective: secretions and
>inability to cough enhances ventilation
effectively to decrease potential
>shallow of atelectasis.
respirations
>febrile 4. Teach client to 4. To help thin
>restlessness maintain adequate secretions.
hydration by
Vital Signs drinking at least 8-
10 glasses of
8:00 am fluid/day (if not
contraindicated).
Temperature- 36.2
C 5. Instruct on 5. Promotes
Pulse rate-89 bpm splinting abdomen increased expiratory
Respiratory rate- 25 with pillow during pressure.
cpm coughing efforts.

12:00 nn
 6. Monitor airway 6. Requires if
Temperature- 35.9 for patency and patient cannot
C provide artificial maintain airway
Pulse rate- 89 bpm airways as patency.
Respiratory rate- 23 warranted.
cpm
7. Instruct family to 7. To improve
notify nurse if the ventilation and
client is maximizes air
experiencing exchange.
shortness of breath
or air hunger.

8. Instruct family 8. Promotes prompt

regarding identification of
medications, effects, potential adverse
side effects and reaction to facilitate
symptoms of timely intervention.
adverse effects to
report to nurse or
physician.