NAME: LACANILAO, LYEANNA CLARYSSE F.

DATE: OCTOBER 26,2022

BSN 2 Sec N Group C

ASSESSMENT EXPLANATION OF OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

THE PROBLEM

Subjective: The patient was initially STO: Dx: STO:

hospitalized to receive
"Ubo naman siya ng ubo treatment for pneumonia.
tapos sinusuka nya yung Pneumonia is characterized
dinedede nya” as
by the inflammation of the
verbalized by the
air sacks also known as
mother.
alveoli, which is
responsible for the
Objective:
movement of oxygen into
 Persistent cough and out of the bloodstream.
 Adventitious lung Normally, the oxygen these
sound: crackles air sacs in our lungs travel
 Patient with all throughout the
Oxygen via nasal bloodstream into the
different parts of the body
cannula at 1-2
LPN to enable our organs to
 Patient with an function normally but with
patients with pneumonia,
ongoing IVF of
the air sacs may fill with
D5LRS 500 x
fluid or pus which can
25cc/hr
result into a patient to
 Inability to
produce cough with
expectorate phlegm, experience
phlegm shortness of breath due to
 Behavior the body coping up with
observed to be lack of oxygen circulating
irritable and in the body with nausea,
Within 6-12 hours of
effective nursing
interventions:
a) the mother will verbalize
understanding of measures
in managing symptoms of
Pneumonia.
b) the patient report
improved sense of energy
LTO:
Within 3 days of effective
nursing interventions, the
patient will:
a) the patient will maintain
clear, open airway
evidenced by normal breath
sounds.
b) Maintain normal fluid
volume
 Assessed general health status
 Assessed breathing pattern and
depth of respiration
 Assessed cough effectiveness
and productivity
Tx:
 Monitored vital signs
accordingly
 Monitored and regulated IVF
 To assess the specific and (Goal Met)
relevant data to be able to
Within -12 hours of
identify and manage
effective nursing
problems of patient.
interventions the
mother verbalized
 To determine distress and
measures managing
accumulation of secretions in
symptoms of
the respiratory system.
Pneumonia; the
patient showed
signs of improved
 To determine the
sense of energy.
characteristic of the cough
related to the severity of the
problem.
 Identify changes in the
LTO:
overall well-being of the
patient. (Goal Partially
Met)
Within 7 days of
 To maintain electrolyte
effective nursing
balance of the patient and to
interventions, the
avoid drying of IVF.
patient the patient
will maintained
 restless vomiting and diarrhea as a c) Clear phlegm readily  Assisted patient into a semi-  To open or maintain airway clear, open airway
 Stool is yellowish secondary system felt with fowler’s position to promote in at rest as evidenced by
in color and Pneumonia patients. airway clearance normal breath
watery in sounds, maintained
consistency  Kept environment allergen free  Allergens can trigger normal breathing,
 Vital signs: by changing soiled linens. coughing which can maintained fluid
T: 36.5 C aggravate the symptom felt volume and cleared
SOURCES: Edx: by the patient. phlegm readily.
SPO2: 95%
HR: 130 bpm CDC. (2022). Pneumonia.
RR: 52 cpm Retrieved from
 Encouraged mother to increase
https://www.cdc.gov/pneu  To promote thinning of the
fluid and nutrition intake by
monia/index.html mucus which helps in
small but frequent breastfeeding
expectorating the phlegm
Nursing Diagnosis:
Mayo Clinic. (n.d.).  Instructed mother to perform
Ineffective Airway
Pneumonia. Retrieved from handwashing frequently  To help reduce growth of
Clearance related to
https://www.mayoclinic.org microorganisms.
retained secretions in
/diseases-conditions/pneum  Advised to report promptly any
the bronchi secondary to
onia/symptoms-causes/syc- untoward feelings and concerns.
Pneumonia.
20354204  To ensure timely intervention
and prevent complications.

Sethi, S. (2022).
Community-Acquired
Pneumonia. Retrieved from
https://www.msdmanuals.c
om/professional/pulmonary
-disorders/pneumonia/
community-acquired-
pneumonia