NURSING CARE PLAN

Situation:Mrs. Catherine Rodriguez is a 24-year-old female, came to the hospital with complaints of fatigue, fever, difficult to breathe and
excessive coughing. She had these complaints in the last 3 days ago. She also having trouble sleeping at night and difficulty to
communicating due to repeated coughing. Her medical diagnosis was pneumonia.

ASSESSMENT NURSING NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATIO

DIAGNOSIS ANALYSIS N
Subjective: Short term: Dependent : - It will Short term
prevent goal:
“I'm having -Based on these -Airway clearance - Within 30 - Examine the transmissi
trouble breathing” symptoms, the is ineffective minutes, breathing rate on and - After 30
as verbalized by the patient and depth, as acquisition minutes-
client is
the patient. -Inflammation of will be able well as chest of 1hour the
diagnosed with the trachea and to achieve movements. infection patient
Community bronchi, edema timely was able
Acquired development, and resolution - Elevate the - Promotes to
Objective: Pneumonia increased sputum of current head of the expectorat achieve
-Shortness of (CAP) secretion infection bed and ion, timely
breath without switch clearing of resolution
-High fever -Positive for complicatio positions often infection of the
-Dyspnea Community n current
-No appetite Acquired - While in an - Incomplet infection
-Continuous Pneumonia (CAP) upright e without
coughing Long term: position, assist immunizat complicat
-Decreased the client with ion may ion.
-Dyspnea and energy, fatigue - Within repeated deep not6 have
restlessness are 24hours- breathing Long term
sufficient
VS follows: symptoms of -Aspiration 48 hours of exercises and acquired goal:
BP: 152/90 impaired gas effective effective active
PICAL HEART exchange nursing coughing immunity - After 24
RATE: 112 bpm interventio hours –
RR: 24 bmp n, the - Assess - Reduce 48 hours
T: 39.1 patient will immunization likelihood of
be able to status and of effective
verbalize history exposure nursing
understand to other interventi
ing on how - Change the infectious on, the
to prevent position pathogens patient
or reduce frequently and was able
risk of provide good - To to
infection. pulmonary prevent verbalize
toilet relapse of understa
pneumoni nding on
- Perform the a, the how to
proper hand patient prevent
washing needs to or reduce
technique complete risk of
before and course of infection.
after any antibiotic
procedure as
done to the prescribed
patient
- Lower
Independent: diaphragm
,
- Assist the promoting
chest
patient with
expansion
deep and
breathing expectorat
exercise ion of
secretions
- Force fluid to .
at least
3000ml per - Deep
breathing
day and often
facilitates
warm, rather expansion
than cold of the
fluids. lungs and
smaller
- Demonstrate airways.
or help patient
learn to
perform
activity like
splinting chest
 and effective
cough while in
upright
position

Collaborative:

- Administer
prescribed
antimicrobial
agents as
ordered

- Limit the
visitor