NURSING CARE PLANS

Cues Nursing Rationale Goal/Outcome Nursing Rationale Evaluation

Diagnosis Criteria Intervention
1. Subjective Hyperthermia Pneumonia is an infection that After 30 minutes of Goal met.
related to inflames your lungs' air sacs effective intervention, the 1. Independent
“Mainit akon infection in the (alveoli). The air sacs may fill patient will maintain body After 30 minutes
pamatyagan kag lungs up with fluid or pus, causing temperature within a. Assessment of effective
nagapalanuka symptoms such as a cough, normal range. intervention, the
ko,” as fever, chills and trouble Assess patient’s vital signs Monitoring vital patient as able to
verbalized by breathing. Fever may rise as Outcome Criteria: (T, PR, RR) and Oxygen signs and Oxygen maintain body
the patient. high as a dangerous 105 Saturation. Saturation frequently temperature
degrees F, with profuse a. Patient will display Vital (at least every 4 within normal
2. Objective sweating and rapidly increased signs (T, RR, and PR) and hours) or with a range as
Fever (T-38.2⁰C) breathing and pulse rate. Oxygen Saturation within continuous evidenced by
Infections cause most fevers. normal level. monitoring device normal vital
X-ray result You get a fever because your enables to detect any signs, balanced
reveals body is trying to kill the virus b. Patient will not exhibit increase/decrease, fluid intake and
Pneumonia or bacteria that caused the any signs of dehydration which may serve as a output due to
infection. Most of those such as nausea and warning that the managed nausea
PR-125bpm bacteria and viruses do well vomiting. patient’s condition is and vomiting, and
when your body is at your worsening. WBC count
RR-44bpm normal temperature. But if c. Patient’s WBC count reduced into its
you have a fever, it is harder will be reduced into its normal number.
Nausea and for them to survive. normal number. Monitor fluid intake and Fluid resuscitation
vomiting urine output may be required to
References: correct dehydration.
WBC The patient who is
significantly
https://medlineplus.gov/fever dehydrated is no
.html#:~:text=Infections longer able to sweat,
%20cause%20most which is necessary
%20fevers.,harder%20for for evaporative
%20them%20to%20survive. cooling.

Adjust and monitor
environmental factors like
room temperature and bed
linens as indicated.
Determine the patient’s age
and weight.
Provide TSB as a measure.
b. Health Teachings
Teach patient to eliminate
excess clothing and covers.
2. Dependent
Administer IV Fluid as
ordered; monitor fluid
replacement levels closely
Room temperature
may be accustomed
to near normal body
temperature and
blankets and linens
may be adjusted as
indicated to regulate
temperature of the
patient.
Extremes of age or
weight increase the
risk for the inability
to control body
temperature.
To lower the patient’s
temperature.
Exposing skin to
room air decreases
warmth and
increases evaporative
cooling.
Replaces fluid lost by
vomiting, insensible
loss and
perspiration.
 Give antipyretic medications Antipyretic
as prescribed. medications lower
body temperature by
blocking the
synthesis of
prostaglandins that
act in the
hypothalamus.

Administer antibiotics. To prevent infection

from getting worse
which causes
hyperthermia.

Ready oxygen therapy for Hyperthermia

extreme cases. increases the
metabolic demand
for oxygen.

3. Collaborative

Collaborate with the Medical Increased WBC

Technologist for the patient’s indicates infection
WBC count update. that causes fever.

Cues Nursing Rationale Goal/Outcome Nursing Rationale Evaluation

Diagnosis Criteria Intervention
1. Subjective Ineffective The lungs react to infectious organisms by After 1 hour of 1. Independent Goal partially met.
Airway mounting an immune response to get rid of effective nursing
“Indi ko Clearance the infection. Sputum production increases intervention, client a. Assessment After 1 hour of
kaginhawa related to Assess patient’s Monitoring vital signs and effective nursing
to help destroy invading microorganisms will identify and
kung maghigda increased vital signs (PR, Oxygen Saturation intervention, the
sputum when you have an infection. In general, the demonstrate RR) and Oxygen frequently (at least every
ko,” as mucus should decrease to normal levels behaviors to client had identified
production Saturation. 4 hours) or with a
verbalized by within a few days after your recovery. achieve airway continuous monitoring and demonstrated
from the
the patient. respiratory Excess mucus production—particularly if it clearance. device enables to detect behaviors to achieve
tract is uncleared and chronic—can have any increase/decrease, airway clearance as
consequences such as breathing difficulties which may serve as a evidenced by Vital
warning that the patient’s signs (PR and RR)
and increased risk of infection. Outcome Criteria: condition is worsening. and Oxygen
2. Objective a. Patient will Saturation within
Assess the rate, To avoid tachypnea,
display Vital signs normal range,
Infiltrates seen Reference: rhythm, and shallow breaths and
(RR,PR) and depth of patent airway with
on chest x-ray asymmetric chest
Causes and Risk Factors of Increased Oxygen Saturation respiration, chest cleared breathing
film suggest movement which happen
Mucus Production. Retrieved from: within normal level. movement, and sounds, reduced
Pneumonia to compensate to airway
use of accessory secretions/sputum
https://www.verywellhealth.com/increased- obstruction. Use of
b. Patient will muscles. due to diminished
Non-Productive mucus-production-914907 accessory muscles
maintain patent coughing, and not
Cough noted increases chest excursion
airway with breath making use of
to facilitate effective
RR- 44 bpm sounds clearing. accessory muscles
breathing.
for breathing.
PR- 125 bpm c. Patient will However, there are
Coughing is the most
effectively clear Assess cough still infiltrations due
SPO2-92% with effective way to remove
secretions/sputum effectiveness and to pneumonia seen
O2 (hypoxemia) secretions.
through productivity
on the X-ray film
pharmacological but was not as
Irregular
and non- worse as before.
shallow breaths
pharmacological Decreased airflow occurs
through mouth
interventions. in areas with
Auscultate lung
Uses accessory fields, noting consolidated fluid.
muscles for d. Patient will avoid areas of Bronchial breath sounds
breathing using accessory decreased or can also occur in these
muscles for absent airflow consolidated areas or in
Bilateral course and adventitious
breathing. response to fluid
crackles on breath sounds
accumulation.
lower lobes e. Patient’s X-ray
with decreased will show no
b. Health
breath sounds infiltrations caused Teachings
at posterior by Pneumonia.
area Elevate head of Repositioning the child
bed, and
will prevent pooling of
encourage the
patient to secretions.
reposition or
change position
frequently.

Facilitates maximum
Teach and assist
expansion of the lungs
patient with
proper deep- and smaller airways, and
breathing improves the productivity
exercises. of cough.

Demonstrate
proper and A reflex and a natural
effective self-cleaning mechanism
coughing while in that assists the cilia to
upright position. maintain patent airways.
Encourage
It is the most helpful way
patient to do so
frequently. to remove most
secretions.
Suggest Chest Used to encourage the
Physical Therapy movement of mucus and
and assist prevent obstruction.
patient in doing
the procedure.

2. Dependent
Intravenous therapy is an
Administer IV effective and fast-acting
Fluid as ordered; way to administer fluid or
monitor fluid medication treatment.
replacement
levels closely

Humidified oxygen may

Use humidified help labored breathing
oxygen or
and prevent hypoxemia.
humidifier at
bedside.

Nebulizers humidify the

Administer
airway to thin secretions
medications such
as and facilitate liquefaction
bronchodilators and expectoration of
(Salbutamol Neb secretions.
1 respoule q6h)
as ordered.

3. Collaborative Bronchoscopy is
occasionally needed to
Assist with remove mucous plugs,
bronchoscopy drain purulent secretions,
 and/or obtain lavage samples for
thoracentesis, if culture and sensitivity.
indicated. Thoracentesis is done to
drain associated pleural
effusions and prevent
atelectasis.

Follows progress and

effects and extent of
Collaborate with pneumonia. Therapeutic
the Radiologist regimen, and may
for the patient’s facilitate necessary
serial X-rays. alterations in therapy

Cues Nursing Rationale Goal/Outcome Nursing Rationale Evaluation

Diagnosis Criteria Intervention
1. Subjective Impaired Gas The lungs react to infectious organisms by After 1 hour of 1. Independent Goal partially met.
Exchange mounting an immune response to get rid of effective nursing
“Nabudlayan ko related to the infection. Sputum production increases intervention, After 1 hour of
magginhawa,” Collection of to help destroy invading microorganisms patient will effective nursing
as verbalized by a. Assessment intervention, the
mucus in when you have an infection. In general, the demonstrate
the patient. airways. mucus should decrease to normal levels improved Assess patient’s To establish baseline patient
within a few days after your recovery. ventilation and vital signs (T, PR, data. Pulse oximetry demonstrated
Excess mucus production—particularly if it oxygenation of RR) and Oxygen detects changes in improved
is uncleared and chronic—can have tissues by ABGs Saturation/Pulse oxygenation. ventilation and
 consequences such as breathing difficulties within patient’s oximetry. oxygenation of
and increased risk of infection. acceptable range tissues by ABGs
2. Objective and absence of To avoid tachypnea, within patient’s
symptoms of shallow breaths and acceptable range
Infiltrates seen Assess the rate, asymmetric chest
on chest x-ray Reference: respiratory rhythm, and and absence of
distress. movement which happen symptoms of
film suggest depth of to compensate to airway
Pneumonia Causes and Risk Factors of Increased respiration, chest respiratory distress
Mucus Production. Retrieved from: obstruction. Use of as evidenced by
movement, and accessory muscles
Non-Productive https://www.verywellhealth.com/increased- Outcome Criteria: use of accessory Vital signs (T, PR
Cough noted mucus-production-914907 increases chest excursion and RR) and
muscles. to facilitate effective
a. Patient will Oxygen Saturation
T- 38.2⁰C display Vital signs breathing. within normal
(T, RR,PR) and Restlessness, irritation, range, patent
RR- 44 bpm Assess mental
Oxygen Saturation confusion, and airway with cleared
PR- 125 bpm within normal level. status, breathing sounds,
restlessness, and somnolence may reflect
b. Patient will changes in level hypoxemia and decreased reduced
SPO2-92% with
maintain patent of consciousness cerebral oxygenation and secretions/sputum
O2 (hypoxemia) due to diminished
airway with breath may require further
intervention. coughing, not
Irregular sounds clearing. making use of
shallow breaths
c. Patient will Auscultate lung Decreased airflow occurs accessory muscles
through mouth
fields, noting in areas with for breathing, and
effectively clear
Uses accessory areas of consolidated fluid. showed no signs of
secretions/sputum
muscles for through decreased or Bronchial breath sounds irritability.
breathing absent airflow can also occur in these However, there are
pharmacological
and adventitious consolidated areas or in still infiltrations
and non-
Irritability breath sounds response to fluid due to pneumonia
pharmacological
accumulation. seen on the X-ray
Bilateral course interventions.
film but was not as
crackles on
d. Patient will avoid worse as before.
lower lobes with b. Health
using accessory
decreased
breath sounds muscles for Teachings
at posterior area breathing.
Elevate head and These measures promote
e. Patient’s X-ray encourage maximum chest
will show no frequent position expansion, mobilize
infiltrations caused changes, deep secretions and improve
by Pneumonia. breathing, and ventilation.
effective
f. Patient will show coughing.
no signs of
irritability.

Suggest Chest Used to encourage the

Physical Therapy movement of mucus and
and assist prevent obstruction.
patient in doing
the procedure.

Prevents over exhaustion

Maintain bed and reduces oxygen
rest. demands to facilitate
resolution of infection.

Encourage use of Relaxation techniques

relaxation help conserve energy that
techniques and can be used for effective
diversional breathing and coughing
efforts.
activities.

2. Dependent Intravenous therapy is an

effective and fast-acting
Administer IV way to administer fluid or
Fluid as ordered; medication treatment.
monitor fluid
replacement
levels closely
The purpose of oxygen
therapy is to maintain
PaO2 above 60 mmHg.
Administer Oxygen is administered
oxygen therapy by the method that
via mask provides appropriate
delivery within the
patient’s tolerance.

Humidified oxygen may

help labored breathing
and prevent hypoxemia.
Use humidified
oxygen or
humidifier at
bedside.
Nebulizers humidify the
airway to thin secretions
Administer and facilitate liquefaction
medications such and expectoration of
as secretions.
bronchodilators
(Salbutamol Neb
1 respoule q6h)
as ordered.
To lower the patient’s
temperature. High fever
Administer (common in bacterial
antibiotics as pneumonia and
ordered. influenza) greatly
increases metabolic
demands and oxygen
consumption and alters
cellular oxygenation.

Bronchoscopy is
3. Collaborative occasionally needed to
remove mucous plugs,
Assist with drain purulent
bronchoscopy secretions, and obtain
and/or lavage samples for
thoracentesis, if culture and sensitivity.
indicated. Thoracentesis is done to
drain associated pleural
effusions and prevent
atelectasis.
 Follows progress and
effects and extent of
pneumonia. Therapeutic
regimen, and may
facilitate necessary
Collaborate with alterations in therapy
the Radiologist
for the patient’s
serial X-rays.