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NURSING CARE PLAN

NURSING SCIENTIFIC
DATA PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS BACKGROUND
Subjective: Ineffective Pneumonia is an Short term goal: Independent: Independent: Short term goal:
“nahihirapan akong airway excess of fluid in  Assess LOC and  To identify After 2 hours of nursing
huminga” as verbalized clearance the lungs After 2 hours of ability to potential intervention, goals are
by the patient. related to resulting from an nursing intervention protect own airway met as the patient:
thickened inflammatory the patient will be airway problems,  Maintained a
Objective: mucus process. The able to: patent airway
- (+) SOB secretions as inflammation is • Maintain a
 Monitor vital  for baseline  Expectorated
- (+) lethargic evidenced by triggered by patent airway signs data secretions
- (+) productive ineffective many infectious • Expectorate  Improved oxygen
cough cough and organisms and by secretions  Evaluate exchange as
- (+) greenish coarse crackles inhalation of • Improve  To determine evidenced by
patient’s gag
sputum irritating agents. oxygen ability to pulse oximetry
reflex, amount
- (+) coarse Infectious exchange (e.g., protect own results within
pneumonias are pulse oximetry and type of normal range
crackles in the airway
categorized as results within secretions, and
right lower lobe (RLL)  To maximize
community normal range swallowing Long term goal:
effort
Vital signs taken as acquired or abilities
follows: hospital acquired Long term goal: After 8 hours of nursing
depending on  Encourage deep  To improve intervention, goals are
BP: 130/80 mmHg where the patient After 8 hours of breathing and met as the patient:
lung function
HR: 103 bpm was exposed to nursing intervention coughing  Demonstrated
RR: 27 cpm infectious agent. the patient will be exercises behaviors to
able to: improve or
Temp.: 38.6⸰C SpO2: maintain clear
92% -- now  Demonstrate  Educate the airway
supplemental oxygen behaviors to
patient about
improve or  Identified
smoking
 maintain clear cessations and  To ascertain potential
airway how it affects patient’s status complications
our health and note and how to
 Identify effects of initiate
potential  Auscultate treatment in appropriate
complications breath sounds preventive
and how to and assess air actions.
initiate movement  clearing
appropriate
airways
preventive  Observe for
actions. signs of
respiratory
distress  For sleep
apnea
Dependent:
 Administer
analgesic
Dependent:
 To improve
cough when
pain is
 Administer inhibiting
expectorants/ effort.
bronchodilator
s  To relax
smooth
respiratory
Collaborative: musculature
 Obtain sputum
specimen Collaborative:
 To point to
effective
antimicrobial
agent
 NURSING SCIENTIFIC
DATA PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS BACKGROUND
Subjective: Hyperthermia Sepsis Short term: Independent: Independent: Short term:
“linalagnat po ako na may related to - After 4 hours of - After 4 hours of
kasamang panginginig” as increased Pooling of nursing  Monitor  Temperature of nursing
verbalized by the patient. metabolic rate as bacteria in the interventions, the temperature- 38.90 - 41.10 interventions,
evidenced by bloodstream patient will have a degree and suggest acute severe the patient has a
Objective: increased temp of pattern. Note infectious disease
body temperature body
(+) lethargic 38.6’C, flushed shaking chills process. Fever
Inflammatory below 37.8. temperature
(+) diaphoretic skin, increase and pattern may aid in
heart, and process initiated diaphoresis. diagnosis. below 37.8.
(+) flushed skin respiratory rate.
Long term:
Vascular changes
After 8 hours of Long term:
(vasodilation,  Monitor  Room temperature
Vital signs taken as nursing After 8 hours of
increase environmental and linens should be
follows: interventions the nursing
capillary temperature. altered to maintain
patient will have a interventions
permeability, Limit or add near-normal body
BP: 130/80 mmHg body temperature the patient has
decrease blood linens, as temperature.
HR: 103 bpm within normal a body
flow) indicated.
RR: 27 cpm range; temperature
within normal
Temp.: 38.6⸰C Cellular changes the pt will range 36.5C;
(increase  Provide tepid  TSB helps in
verbalize comfort
SpO2: 92% -- now leukocytes, sponge bath. lowering the body
and will have the pt was able
supplemental oxygen release of Do not use temperature and
knowledge about to verbalize
chemical alcohol. alcohol cools the
the disease comfort and
mediators) as a skin too rapidly,
process and have knowledge
compensatory causing shivering.
proper treatment. about the
mechanism disease process
and proper
 Remove excess  This decrease
 Local effects clothing. warmth and treatment.
(erythema, pain, increase evaporative
impaired cooling. After the nursing
functioning) interventions, the
goals are met.
Systemic effect  Promote a
(FEVER) well- ventilated  To promote clear
area to patient. flow of air in the
patient’s area. One
way of promoting
heat loss.

 Advise patient
to increase oral  Additional fluids
fluid intake. help prevent
elevated
temperature
associated with
dehydration.
 Maintain bed
rest.

 Reduce metabolic
demands/ oxygen
 Provide high- consumption.
calorie diet.

 To meet increased
 Educate pt metabolic demands.
with the
 disease process
and advise SO  Teaching the
to do TSB when Support system, the
patient feels right way to do TSB
hot. Lukewarm will help in knowing
water only. what to do.

 Monitor pulse
rate and
respiratory
rate
 To evaluate
effectiveness
of independent
Dependent: nursing
 Administer regimen
medications
as indicated.
Dependent:
 Physicians are
knowledgeable
 Paracetamo and the only one
l 300mg IV who is allowed
Q4 PRN to prescribe
drug.

 Paracetamol is a
common
painkiller used
to treat aches
 Administer
and pain. It can
IVF also be used to
reduce a high
temperature.

 To replenish
fluid losses
during shivering
and chills.
 NURSING SCIENTIFIC
DATA PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS BACKGROUND
Subjective: Impaired gas Pneumonia is an Short term: Independent: Independent: Short term:
“Nahihirapan ako huminga.” exchange related to excess of fluid in After 4 hours of After 4 hours of
as verbalized by the patient. collection of the lungs nursing  Asses  Manifestation of nursing
secretions affecting resulting from an interventions, the respiratory respiratory distress interventions,
Objective: oxygen exchange inflammatory patient will achieve rate, depth and is dependent on the patient had
(+) Dyspnea across alveolar process. The ease. indicative of the
timely resolution of achieved timely
(+) Tachycardia membrane. inflammation is degree of lung
current infection resolution of
triggered by involvement and
(+) Wheezes upon many infectious without current infection
underlying general
auscultation organisms and by complications. status. without
inhalation of complications.
Vital signs taken as
irritating agents.
follows: Long term:
Infectious Long term:  Monitor body  High fever greatly
pneumonias are After 2 days of temperature. increases metabolic After 2 days of
BP: 130/80 mmHg
categorized as nursing demands and nursing
HR: 103 bpm
community interventions the oxygen consumption interventions
RR: 27 cpm
acquired or patient will and alters cellular the patient was
Temp.: 37.5⸰C hospital acquired oxygenation. able to:
depending on Manifest absence
SpO2: 93% -- Manifest
where the patient of wheezes upon
was exposed to auscultation.  Elevated head  Promote absence of
infectious agent. of the bed and expectoration, wheezes upon
Attain normal change clearing of infection. auscultation.
breathing pattern position
of 20cpm frequently. Attain normal
breathing
pattern of
 Reduces likelihood 20cpm
 Limit visitors of exposure to other
as indicated. infectious
pathogens.
After the nursing
interventions, the
 Isolation technique goals are met.
 Institute may be desired to
isolation prevent spread and
precaution. protect patient from
other infectious
process.

 Stimulates cough or
 Suction as mechanically clears
indicated. airway in patient
who is unable to
cough effectively.

 Facilitates
 Assist with liquefaction and
nebulizer removal of
treatments. secretions.

 Signs of
 Monitor improvement in
effectiveness of condition should
antimicrobial occur within 24-48
 therapy. hrs.

Dependent: Dependent:
 Administer  These drugs are
antimicrobia used to combat
l as most of the
prescribed. microbial
pneumonias.