ASSESSMENT NURSING PLANNING NURSING RATIONALE

DIAGNOSIS
INTERVENTIONS

Objective: Ineffective After 4 hours of Independent:

breathing pattern nursing interventions,
 Shortness of related to
the patient will be able
breath shortness of to verbalize
 Dry cough breath. understanding of
causative factors and
demonstrate behaviors
condition.
that would improve
breathing pattern
 Establish rapport.  To gain pt.’s
Trust
 Assess pt.’s  To obtain baseline
data
 Serve to track
important changes
 VS monitor and
record.
 to check for the
presence of
 Auscultate breath adventitious breath
sounds and assess sounds
airway pattern.

 To minimize
difficulty in
breathing
 Elevate head of the
bed and change
position of the pt.
every2 hours.
 To maximize effort
for expectoration.
 Encourage deep
breathing and
coughing exercises.  To prevent fatigue.

 Encourage increase  For management

in fluid intake. of underlying
pulmonary
ASSESSMENT
ASSESSMENT NURSING
NURSING PLANNING
PLANNING NURSING
NURSING RATIONALE
RATIONALE
DIAGNOSIS
DIAGNOSIS
INTERVENTIONS
INTERVENTIONS

Objective:
Objective: Anxiety
Deficient
Hyperthermia
related AfterAfter
1 hour1 hour
of nursing
of nursing Independent:
Independent:
to unknown
knowledge
related to illness
interventions,
interventions,
the the
  Body
Fear Inaccurateetiology monitor   Room
related
or trauma
of the
to patient
patient
will be
willable
be toable to  Recognize
 Adjust
Render andphysical Since Based
a causetemperature
onof
follow- disease.
temperature insufficient appear
verbalize
maintains
relaxed body
and awareness
comfort
environmental
of for
the the anxiety
Maslow’s
may cannot
be theory,
 Shakiness
throughtheof
above information reporttemperature
understanding
that anxietybelow
isof 39° patient’s
patient.
factors
anxiety.
like room alwaysbasic
accustomed
be physiological
to near
 instruction
normal
Worried reduced
condition,
C (102.2°
to a F) disease
and temperature and identified,
needs the
normal must
bodybe
aboutrange
or perfor- manageable
process,maintains
patient level.
and treatment.
BP bed linens as patient
addressed
temperature
may feelbeforeas
and
changemance
in on a and HR within normal indicated. thoughthethe
blankets
patient
feelings
and linens
 Hot, flushed
test or
life event; limits. beingmay
education.
experienced
be adjusted as
skin
procedure are counterfeit.
Ensuring physical
indicated to
insomnia
 Increased Acknowledgment
comfort allows the
regulate
 Heartheart rate of thetemperature
patient
patient’s
to of the
palpitations feelings
concentrate
patient.
validateson
 Increased  feelings
the what is and
Exposing being
skin to
 Weakness  Eliminate excess
respiratory communicates
discussed
room air decreases
or
rate clothing and covers.
 Anorexia acceptance
demonstrated.
warmth ofand
thoseincreases
feelings.
 Loss of
 Grant a calm and  evaporative
A calm
appetite
peaceful environment
cooling.
 Use presence, touch  If allows
the patient
the patient
is
 Malaise or environment
 Encourage ample  Being supportive
(with permission),
without to concentrate
dehydrated or and
weakness fluid intake and approachable
verbalization, andby
interruption. focus more fluid
diaphoretic,
mouth. promotes
 Seizures demeanor to remind completely.
loss contributes to
communication.
patients that they fever.
are not alone and to  Conveying respect
 Provide an
encourage
 Evaporative  Alcohol
is especially
cools the
atmosphere
expression
cooling:or coolofwith a
respect, openness, important
skin too rapidly,
when
clarification
tepid bath;
of do not providing
causing shivering.
trust,
needs, and
useconcerns,
alcohol
collaboration. education to
unknowns, and patients with
questions.
 Raise the side rails  This
different
is tovalues
ensure
at all times. and beliefs
patient’s safety
about
healthwithout
even and illness.
the
 Familiarize patient  presence
Awareness of of
theseizure
with the
 Explore reactions  activity.
Assessment assists
environment
environment and the nurse
promotes in
comfort
ASSESSMENT NURSING PLANNING NURSING RATIONALE
DIAGNOSIS
INTERVENTIONS

Objective: Infection related After 1 hour of nursing Independent:

to failure to interventions, the
 Fever  Ensure that any  This reduces or
avoid pathogen patient will be able to
articles used are
 Fatigue/tire secondary to free of infection, as
exposure to evidenced by normal properly disinfected
dness or sterilized before
COVID-19. vital signs and absence
 Difficulty of signs and symptoms use.
of breathing  Wash hands or
of infection.
perform hand  Friction and
(in severe
hygiene before
cases)
having contact with
the patient. Also
impart these duties
to the patient and
their significant
others. Know the
instances when to
perform hand
hygiene or “5
moments for hand
hygiene”:
1. Before touching
a patient.
2. Before clean or
aseptic procedure
(wound dressing,
starting an IV, etc).
3. After body fluid
exposure risk
4. After touching a
patient
5. After touching
the patient’s
surroundings.
 bacterial counts
eliminates germs.
running water
effectively remove
microorganisms
from hands.
Washing between
procedures reduces
the risk of
transmitting
pathogens from
one area of the
body to another.
Wash hands with
antiseptic soap and
water for at least
15 seconds
followed by
alcohol-based hand
rub. If hands were
not in contact with
anyone or anything
in the room, use an
alcohol-based hand
rub and rub until
dry. Plain soap is
good at reducing
but antimicrobial