Name: Monreal, Karen Joy S.

Section: BSN4-B

Scenario: 40 yrs old female, a mother of 2 children came to the hospital complaining of difficulty breathing, loss of appetite and productive
cough that last for about 4 days. Upon auscultating the clients chest there is a crackles sound heard, and a Temp. Of 37.9C, RR-25breaths/min,
PR- 105beats/min, O2sat- 93 and a BP- 130/90mmhg.
 Assessment Diagnosis Planning Intervention Evaluation
Subjective cue: -Ineffective airway -After 4hrs of nursing intervention Goal Met!
-The client verbalize of clearance related to the patient will display a patent
difficulty breathing, loss increased sputum airway with breath sounds After 4hrs of nursing
of appetite and production as evidenced clearing, absence of dyspnea, as intervention the patient
productive cough that by crackles sound upon evidenced by keeping a patent display a patent airway
last for about 4 days. auscultating. airway and effectively clearing with breath sounds
secretions. clearing, absence of
Objective cues: dyspnea, as evidenced
-Dyspnea -Position the patient in high -Positioned patient in by keeping a patent
-Crackles fowler's position. high fowler’s. airway and effectively
-Productive Cough R- Doing so would lower the clearing secretions.
Vital Sign: diaphragm and promote chest -Performing deep-
-Temp. 37.9C expansion also expectoration of breathing and proper Vital Sign:
-RR-25breaths/m secretions. coughing to eliminate -Temp. 36.7C
-PR- 105beats/m sputum. -RR-15breaths/m
-SpO2- 93% -Teach the patient with proper -PR- 80beats/m
-BP- 130/90mmhg. deep-breathing exercises and -Drinking 8-10glasses of -SpO2- 97%
demonstrate proper effective water per day. -BP- 110/80mmhg.
coughing while in an upright
position. -Administered sponge
bath to decrease body
temperature.
R-Deep breathing
exercises facilitate the maximum -Administered nebulizer.
expansion of the lungs and smaller
airways and improve the -Administered
productivity of cough. supplemental oxygen and
Coughing is a reflex and a natural medication such us
self-cleaning mechanism that bronchodilators.
assists the cilia in maintaining
patent airways.

-Maintain adequate hydration

by encouraging client to drink
atleast 8-10glasses of water a day.
R-Fluids, especially warm liquids,
aid in the mobilization and
expectoration of secretions. Fluids
help maintain hydration and
increase ciliary action to remove
secretions and reduce viscosity.
 Assessment Diagnosis Planning Intervention Evaluation
Subjective cue: -Ineffective Breathing -After 4hrs of nursing intervention Goal Met!
-The client verbalize of Pattern related to patient will be able to
difficulty breathing, loss difficulty of breathing. maintains an effective breathing After 4hrs of nursing
of appetite and pattern, as evidenced by relaxed intervention patient able
productive cough that breathing at normal rate and depth to maintained an
last for about 4 days. and absence of dyspnea. effective breathing
pattern, as evidenced by
Objective cues: -Assessed and recorded relaxed breathing at
-Dyspnea -Assess and record respiratory respiratory rate and normal rate and depth
-Crackles rate and depth at least every 2 depth after 2 hours. and absence of dyspnea.
-Productive Cough hours.
Vital Sign: R-The average respiratory rate for -Auscultated breath Vital Sign:
-Temp. 37.9C adults is 10 to 20 breaths per sounds after (2) hours. -Temp. 36.7C
-RR-25breaths/m minute. It is important to take -RR-15breaths/m
-PR- 105beats/m action when there is an alteration -Positioned the patient in -PR- 80beats/m
-SpO2- 93% in breathing patterns to detect high fowler’s. -SpO2- 97%
-BP- 130/90mmhg. early signs of respiratory -BP- 110/80mmhg.
compromise. -Patient able to mobilize
their own secretions with
-Auscultate breath sounds at successful coughing
least every (2) hours. maintaining clear
R-This is to detect decreased or airway.
adventitious breath sounds.
-Performed suction as
-Position the patient in high prescribe by physician.
fowler’s.
R-A high fowler’s position
permits maximum lung excursion
and chest expansion.
 -Maintain a clear airway by
encouraging the patient to
mobilize their own secretions with
successful coughing.
R-This facilitates adequate
clearance of secretions.

-Suction secretions as prescribe

by physician.
R-This is to clear the blockage in
the airway.

Reference:
https://nurseslabs.com/pneumonia-
nursing-care-plans/
 Assessment Diagnosis Planning Intervention Evaluation
Subjective cue: -Impaired gas exchange -After 4hrs of nursing intervention Goal Met!
-The client verbalize of related to collection of patient will demonstrate improved
difficulty breathing, loss mucus in airways. ventilation and oxygenation of After 4hrs of nursing
of appetite and tissues by ABGs within the intervention patient
productive cough that patient’s acceptable range and demonstrated improved
last for about 4 days. absence of symptoms of ventilation and
respiratory distress. oxygenation of tissues by
Objective cues: ABGs within the
-Dyspnea -Assess respiration's, note -Assessed patients patient’s acceptable
-Crackles quality, rate, rhythm, depth, use of respiration's, noted range and absence of
-Productive Cough accessory muscles, ease, and quality, rate, rhythm, symptoms of respiratory
Vital Sign: position assumed for easy depth, use of accessory distress.
-Temp. 37.9C breathing. muscles.
-RR-25breaths/m R-Manifestations of respiratory Vital Sign:
-PR- 105beats/m distress are dependent -Assessed mental status, -Temp. 36.7C
-SpO2- 93% on/indicative of the degree of lung patient able to respond -RR-15breaths/m
-BP- 130/90mmhg. involvement and underlying correctly to the prepared -PR- 80beats/m
general health status as patients questions and mental -SpO2- 97%
adapt their breathing patterns to activity that shows -BP- 110/80mmhg.
facilitate effective gas exchange. mental and conscious
level of the patient.
- Assess mental status,
restlessness, and changes in the -Patient able to relax by
level of consciousness. playing her favorite
R-Restlessness, music and playing fun
irritation, confusion, and board games.
somnolence may reflect
hypoxemia and decreased cerebral -Administered
oxygenation and require further supplemental oxygen by
intervention. Check pulse nasal cannula, mask,
oximetry results with any mental venturi mask.
status changes in older adults.

-Maintain bedrest by planning

activity and rest periods to
minimize energy use. Encourage
the use of relaxation techniques
and diversional activities.
R-It prevents over exhaustion and
reduces oxygen demands to
facilitate the resolution of
infection. Relaxation techniques