ASSESSMENT EXPLANATION OF PLANNING INTERVENTIONS RATIONALE EVALUATION

THE PROBLEM
Independent:
Subjective: Pneumonia is an Short Term:  Assess vital signs  To provide Short Term:
“May halak pa sya infection that inflames Within 4 hours of baseline data The goal was met,
at may plema pa the air sacs in one or nursing interventions, within 4 hours of
rin pag ubo nya” as both lungs. The air sacs the patient airway will  Assess the rate,  Use of accessory nursing
verbalized by the may fill with fluid or be free of secretions rhythm, and depth of muscle indicates interventions, the
client’s mother. pus (purulent as evidenced by respiration, chest an abnormal client airway was
material), causing eupnea and clear lung movement, and use increase in work of free of secretions as
Objectives: cough with phlegm or sounds after coughing. of accessory muscles. breathing evidenced by
 persistent pus, fever, chills, and eupnea and clear
coughing and difficulty breathing. A  Assess cough  Coughing is the lung sounds after
dyspnea variety of organisms, effectiveness and most effective way coughing.
 presence of including bacteria, productivity. to remove
abnormal lung viruses and fungi, can secretions.
sound cause pneumonia. Long Term:
 cyanosis After 3 days of nursing  Auscultate lung  Decreased airflow Long Term:
 eupnea Pneumonia can range interventions, the fields, noting areas of occurs in areas The goal was met,
in seriousness from patient will be able to decreased or absent with consolidated after 3 days of
mild to life- have effective airway airflow and fluid. Bronchial nursing
Nursing Diagnosis threatening. It is most clearance and no adventitious breath breath sounds can interventions, the
Ineffective airway serious for infants. sputum productions sounds: crackles, also occur in these client has effective
clearance related with normal lung wheezes. consolidated airway clearance
to increased sounds. areas. and no sputum
sputum Reference: productions with
production. Brunner & Suddarth’s  Observe the sputum  Changes in normal lung sounds.
Textbook of Medical- color, viscosity, and sputum
Surgical Nursing 11th odor. Report characteristics
edition by Smeltzer, changes. may indicate
Bare, Hinkle, Cheever infection.
 Elevate head of bed,
change position  Doing so would
frequently. lower the
diaphragm and
promote chest
 expansion.

 Assist and monitor  Humidify the

effects of nebulizer airway to thin
treatment and other secretions and
respiratory facilitates
physiotherapy. liquefaction and
expectoration of
secretions.
Dependent:
 Administer  Used to facilitate
bronchodilators as respiration by
ordered. dilating the
airways.

Reference:
Herdman, H.T., (2020)
NANDA International
Nursing Diagnoses:
Definitions and
Classification 2018-
2020 11th Edition

ASSESSMENT EXPLANATION OF PLANNING INTERVENTIONS RATIONALE EVALUATION

 THE PROBLEM

Subjective: Nutritional imbalance Short Term: Independent: Short Term:

“Mahina syang is caused by inability of Within 4 hours of  Auscultate for bowel  Bowel sounds may The goal was met,
dumede” as the body to absorb nursing interventions, sounds. Observe for be diminished if within 4 hours of
verbalized by the certain nutrients or the mother will abdominal the infectious nursing
client’s mother. result from a poor diet. express understanding distension. process is severe. interventions, the
Based on the nutrients of feeding techniques Abdominal mother
in short or excess essential to daily distension may demonstrate
supply, imbalances nutritional occur as a result of understanding of
Objectives: create unpleasant side requirements. air swallowing or nutritional
 persistent effects and conditions reflect the principles and
coughing and that could lead to influence of requirements,
dyspnea serious disease. bacterial toxins on feeding techniques,
the (GI) tract. and special needs.

 For infants older  Older infants and

Reference: Long Term: than age 6 months, young toddlers Long Term:
Brunner & Suddarth’s After 3 days of nursing offer solid foods may resist solid The goal was met,
Nursing Diagnosis
Textbook of Medical- interventions, the before formula or foods, preferring after 3 days of
Risk for
Surgical Nursing 11th mother will express breast milk. milk or formula. nursing
Imbalanced
edition by Smeltzer, willingness to interventions, the
Nutrition: Less
Bare, Hinkle, Cheever continue feeding  Record and describe  Dietitian or mother express
Than Body
regimen at home. food intake. Refer nutritional support willingness to
Requirements
family members to a team can continue feeding
related to
dietitian or individualize the regimen at home.
persistent
nutritional support child’s diet within
coughing and
team for dietary prescribed
dyspnea.
management. restrictions.

 Monitor electrolyte  Poor nutritional

values and report status may cause
abnormalities. electrolyte
imbalances.

 Monitor and record  Characteristics of

 the amount, color, vomitus and stools
consistency, and provide clues to
presence of occult nutrient
blood in emesis absorption.
and stools.

 Presence of
 Evaluate general
chronic conditions
nutritional state,
or financial
obtain baseline
limitations can
weight.
contribute to
malnutrition,
lowered resistance
to infection,
and/or delayed
response to
therapy.

Dependent:  To ensure
 Provide parenteral adequate fluid and
fluids, as ordered. electrolyte levels.

Educative:  Correct
positioning and
 Educate the mother attachment are
on proper the most
breastfeeding important thing
techniques such as for successful
latching and position. breastfeeding.

Reference:
Herdman, H.T., (2020)
NANDA International
Nursing Diagnoses:
Definitions and
Classification 2018-
2020 11th Edition