NURSING SCIENTIFIC

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS BACKGROUND

Subjective: Impaired gas CAP is a common Goal: Independent: After 8 hours of

exchange related illness and can nursing
“adda ti uyek na After 8 hours of ● Tachypnea,
to altered affect people of ● Monitor intervention, the
ma’am sa nursing stridor, crackles or client was able to
oxygen supply. all ages. CAP respiration and
marigatan met nga intervention, the wheezes are
often causes breath sounds. establish a normal
umanges tattayen” client will be indicative to
problems like and effective
as verbalized by the able to establish repiratory distress respiratory pattern.
patient’s significant difficulty in a normal and and/or
others. breathing, fever, effective accumulation of
- right sided chest pains, and a respiratory fluid (Nurse's
chest pain cough. CAP pattern. Pocket Guide by
- cough occurs because Doenges et al
(yellow the areas of the Objectives: pp.78)
sputum)
lung which
Independent
absorb oxygen
(alveoli) from the ● Place the client in ● Positioning the
Objective: After 30 minutes client in high
atmosphere of intervention, high fowler’s
position. fowler's position
V/S taken as become filled the client would promote lung
follows: with fluid and be able to have expansion.
BP-125/71 mmHg cannot work normal breath
T-100◦F effectively. respiration and (Fundamentals of
PR-122 bpm breath sounds Nursing by
RR-33 cpm within 20 Elsevier pp.789)
minutes.
- breath
sounds were After 30 minutes ● Increased fluid ● Hydration can
diminished of nursing intake. help liquefy
on the right intervention, the viscous secretions
side in the client would be and improve
upper zone able to have secretion
without the easier breathing. clearance.
presence of (Nurse's Pocket
adventitious After 45 minutes Guide
sounds. of nursing Doenges.79)
intervention, the
client would be
able to mobilize ● Encourage ● Promotes
secretions. frequent position optimal chest
changes and deep expansion and
Dependent drainage of
breathing/coughing
exercises. secretions.
After 15 minutes
of nursing
intervention, the
● Suction is used
client would be ● Suctioning
to clear airway
able to take the when excessive or
medications and viscous secretions
treatment are blocking the
prescribed by the airway or client is
physician within unable to cough
the order time effectively.
and date of (Nurse's Pocket
administration. Guide by Doenges
et al pp.78)
Interdependent

After 15 minutes ● Chest

of nursing Physiotherapy is
intervention, the ● Perform Chest
Physiotherapy. used to
client's relatives
would be able to mechanically
perform proper dislodge tenacious
humidification secretions from
and administer the bronchial
medication via walls. (Nursing
nebulization Care Management
Skill Manual
pp.60)

Dependent:

● Administer ● Bronchodilators
bronchodilators as are anti-
ordered by the inflammtory
drugs,
physician.
excpectorants and
cough
suppressants that
may treat
respiratory
problems.
(Fundamentals of
Nursing by
Elsevier pp.1369)

● Perform oxygen
● Administration
therapy or
of oxygen to
administer oxygen
client to prevent
by nasal cannula. or relieve
 hypoxia.
(Nursing
CareManagement
Skill Manual
pp.55)
● Nebulization is
● Instruct relatives
performed to
to perform proper
deliver finer mist
nebulization at a faster rate to
moisten
membrane.
(Nursing
CareManagement
Skill Manual
pp.69)

NURSING SCIENTIFIC
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS BACKGROUND

Objective: Risk of infection Possibly evidenced Goal: ● Assess ● Incomplete .Goal:

(+) weak related to by risk factors of immunization status immunizations
Within 30 After 30 minutes-
(+) pale Community body fluids, and history. may not have
minutes-1 hour, 1 hour, the patient
Acquired malnutrition and sufficient
the patient will was able to
- oxygen via Pneumonia associated acquired active
be able to achieve timely
nasal condition of immunity.
achieve timely resolution of
cannula
chronic illness, resolution of ● It will prevent current infection
- poor ● Perform the
decrease in ciliary current infection transmission and without
appetite proper handwashing
without complications.
action, complications. technique before acquisition of
immunosuppression and after any infection. Life threatening
. (Doengues, M., Life threatening procedure done to Only:
Moorhouse M., & Only: the patient.
Murr, A, Nurses After 24-48 hours
pocket guide p. Within 24-48 of effective
hours of ● Change position ● Promotes nursing
1005)
effective nursing frequently and cough out, intervention,
intervention, provide good clearing of patient was able to
patient will be pulmonary toilet. infection. verbalize
able to verbalize understanding on
understanding how to prevent or
on how to ● Administer ● To prevent reduce risk of
prevent or prescribed relapse of infection.
reduce risk of antimicrobial agents pneumonia, the
infection. as ordered. patient needs to
complete course
of antibiotics as
prescribed.

● Check the
● Fever is one
presence of elevated
sign of infection
temperature and
that needs
give paracetamol as
immediate
prescribed.
interventions to
prevent
worsening of the
illness.
● Educate the ● It will limit or
patient on the ways reduce
of preventing transmission of
infection such as the infections
proper hand through proper
washing technique. hand washing.

● Encourage
adequate rest ● Facilitates
balance with healing process
moderate activity. and enhances
Promote adequate natural
nutritional intake. resistance.

● Encourage the ● It enhances the

patient to eat immune function
healthy foods that of the body.
can enhance the
immune function
and take necessary
vitamins needed.
 NURSING SCIENTIFIC
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS BACKGROUND

Objective: Ineffective Most acute After 3 hours of ● Monitor and ● To obtain Goal met. After 3
(+) weak breathing pulmonary nursing record vital signs. baseline data. hours of nursing
(+) pale pattern R/T diseases like interventions, interventions, the
respiratory the patient will ● Elevate ● To promote patient have
bronchopneumonia physiological
- cachectic and muscle fatigue is preceded by a have improve HOB as improved
dyspneic breathing appropriate. ease of maximal breathing patterns
change in inspiration
- tachycardia patterns AEB AEB decreased
breathing pattern.
but normal decreased RR. RR-40 cpm
Respiratory failure
rhythm
can be seen with a ● Administer ● To
change in oxygen as ordered. compensate to
respiratory rate, oxygen
change in normal insufficiency.
abdominal and
thoracic patterns ● Give ● To provide
for inspiration and bronchodilators as pharmacologic
expiration, change ordered. relief.
in depth of
ventilation (Vt).
Breathing pattern
changes may occur
in a multitude of
cases from
respiratory muscle
fatigue. Other
responses would
be cyanosis,
irritability,
restlessness,
dyspnea, nasal
flaring, and use of
accessory muscle.