Notre Dame University

College of Health Sciences

Cotabato City

Name of Patient: Tipanero,Leil Name of Student: Michaella Olivia P. Awal

Human Nursing Cues Pathophysiological Nursing Nursing Rationale Evaluation
Response Diagnosis Basis Outcome Interventions
Pattern
E Ineffective S-“May ubo Germs called Within the -Assessed -Use of accessory
X airway sya,dati bacteria or viruses shift the respiratory muscles to breathe
C clearance naadmit nay an usually patient will movements and the indicates an abnormal
H r/t retained sya kasi may cause pneumonia. Pn be able to use of accessory increase in work of
A secretions pneumonia,nga eumonia usually maintain a muscles. breathing.
N yon High risk starts when you normal RR
G na daw ang breathe the germs -Monitor vital signs -To check for any
I pneumonia into your lungs. You especially the RR. unusualities with the
N nya” as may be more likely VS.
G verbalized by to get the disease
mother after having a cold -Auscultate the -Crackles are heard
O-Crackles or the flu. lung sounds when fluid is present.
heard at Left Pneumonia is an There would be
lung field upon infection that possible adventitious
auscultation inflames the air sacs breath sounds that
-prolonged in one or both lungs. needs to be assessed.
expiration The air sacs may fill -Back rubbing done -Back rubbing
phase with fluid or pus
-Productive (purulent material), comforts the patient.
cough noted causing cough with
phlegm or pus, fever, -Encouraged to
chills, and difficulty -Hydration can help
increase milk liquefy viscous
breathing. intake phlegm.
Diagnosis: Pediatric Community Acqured Pneumonia High Risk Name of CI: Prof. Joybelle O.Rpdriguez RN
Room/Ward: Blessed Imelda Ward Date: February 6,2018