ASSESSMENT DIAGNOSIS PLANNING INTERVENTION NURSINGTHEORY EVALUATION

Subjective: Ineffective NURSING

Before the end ofCARE PLAN
INDEPENDENT: Margaret Jean Watson: Philosophy Goal was met:
“Gahagrak kag airway the shift, the patient of Science and Caring
Nabudlayan siya clearance will be able to  Elevate head in At the end of the
magginhawa kag gina related to maintain patent moderate to high “Caring regenerates life energies and shift, the client was
pusong” increased airway as evidenced bed rest with the potentiates our capabilities. The able to display
mucus by: use of pillows. benefits are immeasurable and patency of airway as
As verbalized by the production SHORT TERM  Monitor Oxygen promote self-actualization on both a manifested by:
mother  Decrease of saturation personal and professional level.
bronchial  Assist suction as Caring is a mutually beneficial Client’s respiratory
Objective: secretions indicated experience for both the patient and rate is within normal
- Abnormal breathing  normal  Assist in the nurse, as well as between all range and airways is
sounds: (wheezing) respiration as nebulization of health team members.” free of secretions
- Dyspnea evidenced by Ventolin
- Yellowish secretion absence of Salbutamol
dyspnea and  Assess sputum
VITAL SIGNS: adventitious color, amount, and
RR: 45 breaths per min breath sounds odor.
TEMP: 36.2 DEGREE  Demonstrate  Encouraged steam
CELSIUS increased air inhalation
PR: 120 BEATS/MIN exchange  Encouraged drink
Oxygen saturation: 75%
frequent amount
LONG TERM
CHEST X-RAY: of water
 CHEST X-
Impression RAY
DEPENDENT:
examination
 Pulmonary  Administer
will back to
Congestion its normal medication orally
 Bilateral state (Cefuroxime 500
Pneumonia mg) and
(Prednisone 200
mg)

25
P-CAP (type C) WITH BRONCHIAL ASTHMA
 ASSESSMENT
SUBJECTIVE: Infection related
 Productive Coughing
 Nasal Flare
 Difficulty of breathing
OBJECTIVE:
Laboratory test:
Presence of sticky and yellowish
secretion in mouth and nose.
CBC TESTING:
 Increased amount of
WBC, SEGMENTERS,
and below normal level of
Lymphocytes
- WBC- 18.8
REFERENCE VALUE
OF 4.5-13.0
- SEGMENTERS- 92
REFERENCE VALUE
OF 34-64
- LYMPHOCYTES- 4
DIAGNOSIS PLANNING INTERVENTION NURSING THEORY EVLUATION
SHORT TERM INDEPENDENT: Faye Glenn Partially Met:
to invasion of  In 1 hr. patient  Monitor temperature Abdellah’s Concept of After 24 hours, the
pathogens will be able to  IV REGULATION Twenty-One Nursing client was able to
(Bacteria breath properly.  Demonstrate and Problems exhibit no presence of
Streptococcus  In 1 hr. patient encourage good hand fever. Secretions is
Pneumonaie) will able to washing techniques “To promote good still present but not as
relieve fever.   Change position hygiene and physical abundant as previously
LONG TERM frequently and provide comfort. To promote encountered
 Achieve timely good pulmonary optimal activity,
resolution of hygiene exercise, rest, and
current infection  Limit visitors as sleep. To promote
without indicated safety through
complications.  Encourage adequate prevention of
 Re-testing of rest balanced with accidents, injury, or
CBC will back moderate activity. other trauma and
to its normal Promote adequate through the prevention
value. nutritional intake. of the spread of
 Encourage to drink infection.”
frequent amount of
water
DEPENDENT:
 Aid in administering
25
P-CAP (type C) WITH BRONCHIAL ASTHMA
 REFERENCE VALUE anti-microbial.
OF 24-45 Antibiotics (Cefuroxime
500 mg tablet)

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION NURSING THEORY EVLUATION

25
P-CAP (type C) WITH BRONCHIAL ASTHMA
SUBJECTIVE: Disturbed sleeping SHORT TERM INDEPENDENT: Faye Glenn Abdellah’s SHORT TERM:
“ Indi sa ka katulog pattern related to Within 1 hr. of  Observe and obtain Concept of Twenty One After 1 hour of
mayad kay gina coughing, and adequate nursing from client Nursing Problems adequate nursing
barukoy gid sa ubo” as difficulty of intervention the cough regarding bedtime intervention the patient
verbalized by the breathing. of the patient will stop medication, and “To promote good hygiene and was able to relief
mother and able to rest and numbers hours of physical comfort. To promote difficulty of breathing
sleep. sleep. optimal activity, exercise, rest, and coughing
OBJECTIVE:  Recommend and sleep. To promote safety - GOAL MET
 Persistent LONG TERM limiting used of through prevention of accidents,
coughing Within a day patient cellphone injury, or other trauma and LONG TERM:
 Lethargic will able to complete  eating cold foods through the prevention of the After the shift of
 Dark circle sleeping hours, can that trigger spread of infection.” adequate nursing
under the eyes rest properly and can coughing. intervention, the patient
 Yawning administer wasn’t able to improve
nebulization to DEPENDENT: sleeping pattern
Vital signs: himself.  Assist in
RR: 45bpm nebulization of - Goal not met
HR: 125 bpm Ventolin
Ox sat.: 77% Salbutamol

25
P-CAP (type C) WITH BRONCHIAL ASTHMA
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION NURSING THEORY EVLUATION
SUBJECTIVE: “Masakit akun Acute pain Short term goal: INDEPENDENT Katharine Kolcaba: Short term:
dughan mag ubo” as verbalized by related to After 1-2 hour of  Elevate head of the “The Comfort Theory”
nursing bed, change position The patient relief of pain
the client persistent cough The Comfort Theory
intervention the frequently. and demonstrate relaxed
philosophy proposes
OBJECTIVE: patient will relief Lowers diaphragm, manner; resting/sleeping
that when comfort of
of pain, shown promoting chest patients and/or their
 Use of accessory muscle - Goal met
normal breathing, expansion.
 Productive cough families is enhanced,
 Assist patient with Long term:
(yellowish) demonstrate they can engage more
breathing exercise After several days of
 Restlessness relaxed manner like fully, either
 Deep breathing
 Reports of discomfort: resting/sleeping. consciously or nursing intervention, the
facilitates expansion
pleuritic chest pain subconsciously, in patient will display
Long term goal: of the lungs and
 Intercostal retraction health-seeking patent airway, proper
smaller airway
VS TAKEN: breathing pattern, and
After several days  Assist and monitor behaviors
RR: 39 cpm can engaged in light
of nursing effects of nebulizer
HR: 142 bpm activities.
intervention, the treatment 
Ox sat.: 75%
patient will display  Drink Frequent
- Goal met
patent airway, amount of water
proper breathing
DEPENDENT:
pattern, and can
 Assist in nebulization
engaged in light of Ventolin
activities. Salbutamol

25
P-CAP (type C) WITH BRONCHIAL ASTHMA
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION NURSING THEORY EVLUATION
25
P-CAP (type C) WITH BRONCHIAL ASTHMA
SUBJECTIVE: Imbalanced Short term goal: INDEPENDENT Jean Watson: “Theory of Short term:
“Wala sag gana mag kaun kag kung nutrition less After 4 hours of  Monitor food and Human Caring” States
mag kaun gid man sa gamay than body nursing intervention fluid intake The patient will gain
that “nursing is
gamay” as verbalized by the mother requirements the patient will gain  Plan a healthy back his appetite and can
concerned with
related to back his appetite and balanced diet appropriately verbalized
promoting health,
OBJECTIVE: Increased can appropriately  Offer foods that what foods he wants,
preventing illness, caring
metabolic needs verbalized what foods rich in Vitamin C and relief his fever
Vital signs: for the sick, and
secondary to  Promote drinking
TEMP: 37.3 he wants, and relief restoring health.” It Goal met
fever and frequent amount
RR: 40 cpm his fever. focuses on health
infectious of water Long term:
HR: 145 bpm process  Provide small, promotion, as well as the
Long term goal:
Ox sat.: 94% frequent meals, treatment of disease The patient recovers to
After several days of including dry his pneumonia due to the
nursing intervention, foods (toast, increased food intake of
the patient will crackers) and/or fruits and vegetables and
display patent airway foods that appeal completing the days of
and infection of to the patient taking his antibiotic
Pneumonia will gone medicine.
DEPENDENT:
due to the increased
 Aid in Goal met
food intake of fruits
administering
and vegetable, and anti-microbial.
completing the days Antibiotics
of taking his antibiotic (Cefuroxime 500 mg
medicine tablet)

25
P-CAP (type C) WITH BRONCHIAL ASTHMA