Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective After 2 hours 1. Position pt. in a 1. To promote lung Goal met:
Airway of nursing
semi fowler. expansion and easier
Mother reported Clearance intervention, After 2
breathing.
that pt. was related to the patient will 2. Administer hours of
disease maintain a
experiencing oxygen therapy and 2. To loosen secretion nursing
process as patent airway
shortness of evidenced by with breath monitor oxygen in the lungs. intervention

Breath, cold and SOB, sounds level q 2 hours. , the pt.

3. To remove
restlessness, clearing;
cough. maintained
cough. absence of 3.encourage secretion because

SOB, cough a patent

coughing and deep pneumonia may cause
and cold. airway with
Objective: breathing. thick and tenacious
breath
Wheezing lung Secretions.
4. Administer
sounds sounds
Nebulizer and
4. To increase ciliary
Patient seen medication as per clear, as
action to remove
coughing and drug chart. evidenced
Shortness of secretions and reduce
5. Maintain by absence
Breath. adequate hydration viscosity.
of SOB,
Skin, warm to
5. To mobilize and cold and
touch, afebrile.
expectorate secretion cough.

and increase ciliary

Unstable Vital
Signs action to remove

Mucous secretions.

membranes dry.
V/S taken as Ineffective After 8 hours Goal met:
1.Assess respiratory 1.To detect early signs
follows: breathing of nursing
rate q 4 hrs. of respiratory After 8
pattern intervention,
T-97.7 F hours of
related to pt. will comprise.
2. suction as nursing
P- 154 inflammatory maintain an
intervention
process as effective necessary 2.to clear the blockage
R-38 , pt. was
evidenced by breathing in the airway.
SPO2 -90% 3. educate pt. on able to
changes in pattern.
maintain
rate, depth of different types of 3. To allow pt. to
effective
respiration, breathing eg. participate health breathing
abnormal
Pursed-lip status and improve pattern.
breath sounds
and ventilation.
4. obtain ABG
hypoxemia.
sample and assess 4. to monitor

ABG level. oxygenation and

ventilation status.
Throughout 1.encourage
Risk for Goal met:
the hospital handwashing 1.To prevent or
Infection
stay, pt. will Patient
related to reduce spread of
identify 2.encourage
inadequate remain free
interventions microorganism.
primary adequate bed rest.
from
to prevent or
defence. 2. to facilitates
reduce 3.Administer infection
infection. healing process
antimicrobial agents throughout

as per drug chart. 3. to prevent relapse hospitalizati

of pneumonia and the on.

need to complete
 course of antibiotics

as prescribed.

1.Infections are

indicative with an

increased temperature

and pulse.
Possible
infection of
incision site
related to 2.Patient’s

impairment cooperation is
of skin
necessary to ensure
integrity.
that incision area is

Throughout maintained clean.

hospitalization
3. Health care team
, the incision
site will will maintain sterility
remain free to prevent nosocomial
from infection. infections.