PNEUMONIA

Assessment Nursing Diagnosis Planning Intervention Evaluation

Subj: “Nag sige og Impaired gas Within 8 hours of 1. Establish Goal Partially Met:
suka akong anak exchange related to rendering nursing rapport Within 8 hours of
gahapon, grabe na collection to mucus in care the patient will: 2. Monitor vital rendering nursing care
iyang ka putla sa sige airway secondary to - Have good signs and the patient have:
og ubo grabe and pneumonia hydration status regulate IVF - Good hydration
plema murag ga luwa - Skin warm to 3. Monitor intake status
na iyang mata” As touch and output - Skin warm to
verbalized by the - Have better 4. Assess clinical touch
mother of the patient health status signs for - Maintained
- Maintain dehydration optimal gas
Obj: optimal gas 5. Administer exchange as
- Shortness of exchange as medication as evidence by
breath
- Abnormal evidence by ordered by the unlabored
breath sound unlabored physician respirations
- Productive
cough respirations 6. Health teaching
to the parent of
VS the patient
Temp: 36.5
RR: 28
PR: 110
DIARRHEA

Assessment Nursing Diagnosis Planning Intervention Evaluation

Subj: Risk for electrolyte Within 8 hours of 1. Establish Goal Met
“Grabe akong pag imbalance related to rendering nursing care rapport with
libang nag sige kog excessive loose the patient will: patient. Within 8 hours of
balik balik og cr, basa watery stool - Have good 2. Monitor, rendering nursing care
pod kaayo akong tae secondary to diarrhea hydration status measure and the patient:
nag sakit na akong - Maintain fluid record intake - Have good
lubot sigeg libang” As volume at a and output hydration status
verbalized by the functional level 3. Assess clinical - Maintained fluid
patient - Drink lot of signs of volume at a
fluids hourly dehydration functional level
Obj: - Report 4. Administer IVF - Have taken a
- Loose watery reduction of fluid like lot of fluids
stool for 7 times loose water electrolytes as hourly
already stools prescribed by
the physician
VS. 5. Assess the
Temp: 36.5 cause of
RR: 20 diarrhea &
PR: 87 identify the
BP: 110/60mmhg frequency,
 consistency
and color of the
stool
6. Instruct client to
maintain
hygiene in peri-
anal area
HYPERTENSION

Assessment Nursing Diagnosis Planning Intervention Evaluation

Subj: “Nag lisod jod Ineffective airway Within 8 hours or 1. Establish rapport Goal Partially Met
kog hinga maam, clearance related to rendering nursing with patient Within 8 hours or
murag gina apas nako increased production care the patient will: 2. Monitor vital signs rendering nursing
akong hininga, guot of secretions - Demonstrate 3. Monitor intake and care the patient have:
kaayo akong dughan” behaviours to output - Demonstrated
As verbalized by the improve 4. Auscultate Breath behaviours to
patient airway sounds improve airway
clearance and 5. Observe sputum clearance and
Obj: cough color, odor and cough
- Dyspnea effectively volume effectively
- Productive - Expectorate 6. Encourage patient - Expectorated
Cough secretions to do breathing secretions
- Maintain and coughing - Maintained
VS: patent airway exercise patent airway.
Temp: 36.7 7. Do health teaching
RR: 25 to patient and
PR: 65 family
BP: 100/80
CHRONIC OBSTRCTUCTIVE PULMONARY DISEASE

Assessment Nursing Diagnosis Planning Intervention Evaluation

Subj: Non-compliance to the Within 8 hours or 1. Establish rapport Goal Partially Met:
“Kalit ra ko nalipong og therapeutic regimen rendering nursing with patient
Within 8 hours or
natumba sa balay, grabe related to life long care the patient will: 2. Monitor vital signs
rendering nursing care
kasakit akong ulo og init treatment protocols - Have good 3. Elevate head and
the patient:
kaayo akong pamati” As secondary to blood encourage
- Have good blood
verbalized by the patient hypertension pressure frequent changes
pressure status
status of position
- Have stable
Obj: - Have stable 4. Encourage deep
cardiac rythym
Increased BMI cardiac breathing
- Patient have
Agitated Behaviour rythym 5. Advice the family
verbalized its
Obesity - Patient will to support the
understanding
verbalized client to better and
regarding the
VS: healthy lifetsyle
understandin
disease and
Temp: 36.2 6. Educate patient
g of the
importance of
RR: 20 and family and do
disease and
treatment regimen
PR:90 health teaching
importance
BP: 190/110
of treatment
regimen

URINARY TRACT INFECTION

 Assessment Nursing Diagnosis Planning Intervention Evaluation
Subj. Acute pain related to Within 8 hours of 1. Establish Goal Met
“Sakit kaayo mag ihi biological factors rendering nursing care rapport with Within 8 hours of
maam og medjo ga such as trauma or the patient will: patient rendering nursing care
katol didtos baba dapit activity od disease - Have increased 2. Monitor vitals the patient
maam” process fluid intake signs and - Have increased
- Have good regulation of fluid intake
Obj: perineal hygiene IVF - Has good
- Perineal - Eliminate the 3. Monitor intake perineal
Excoriations infection and and ouput hygiene
- Restlesness prevent 4. Assess for pain - Eliminated the
- Redness and recurrence characteristics infection and
swelling in 5. Encourage prevent
perineal area patient to void recurrence
- Urinalysis frequently
shows pus cells 6. Encourage
& epithelial patient
cells verbalization of
VS: feelings
Temp: 37.3 7. Observe further
RR: 19 complaints
PR: 82
BP: 120/90