Assessment Nursing Goal/ Intervention Rationale Implementation Evaluation

Diagnosis Planning
subjective Data Ineffective to maintain - Assess the - To get the base -assessed the condition Patient’s
breathing normal and condition of the line data of the of the patient. Patient saturation
patient verbalized she pattern improve patient. patient. is having dyspnea, improved to
is having dyspnea related to respiration Decreased sp02. some extent.
and cough. decreased pattern -Provide semi- -to promote
lung fowlers position breathing pattern. -SP02-96%
expansion to patient. -semi-fowlers position -respiration rate
and provided improved
Objective Data inflammatory -to provide steam -to remove 24/min.
process as inhalation and secretions.
-respiratory rate evidence by nebulization as - steam inhalation and
31/min dyspnea, per doctor’s nebulization wd
-decreased SPO2 ineffective order. budecort administered
i.e.- 94-95% without cough as per doctor’s order
oxygen therapy -perform chest -to remove
physiotherapy. secretions.
- chest physiotherapy
-Administer -to promote performed.
oxygen therapy respiration.
as per doctor’s -Oxygen therapy via
order. nasal prongs, 2 L/min
as per doctor’s order
Assessment Nursing Goal/ Planning Intervention Rationale Implementation Evaluation
Diagnosis
subjective Data Decreased to make patient - Assess the - To get the base - assessed the normal cardiac
cardiac display condition of the line data of the condition of the output
patient complains of output related hemodynamically patient. patient. patient. BP 110/60 maintained to
chest heaviness. to increase stability mmhg, hr-108/min some extent
peripheral
resistance and -Assess the sign -to evaluation - the sign of -BP:
abnormal of myocardial early warning myocardial ischemia 110/70mmhg.
Objective Data arteriovenous ischemia and ecg signs. and ecg changes
oxygen changes. assessed, patient have HR: 98
-heart rate 108/min difference as dysrhythmias, no beat/min
-bp: 110/60mmhg evidence by other complication
- ECG findings: dysrhythmias, present
tachycardia, hypotension,
dysrhythmias tachycardia. -to monitor -to evaluate early - cardiac rhythm
cardiac rhythm warning signs. continuously
continuously. monitored.

-monitor vital -to evaluate early -vital sign monitored

signs warning signs. frequently.
continuously.

-Administer -to maintain -I/V fluid RL on flow

fluids drugs as normal cardiac @80ml/hr as per
per doctor’s output doctors order
order.
Assessment Nursing Goal/ Intervention Rationale Implementation Evaluation
Diagnosis Planning
subjective Data Ineffective To maintain - Assess the - To get the - assessed the Patent airway
airway patent airway condition of the base line data condition of the maintained to
Patient complaint clearance clearance. patient. of the patient. patient, increased some extent.
of sputum related to sputum production.
production. bronchial
inflammation as -Provide semi -to maintain -semi fowlers SPO2- 98%
evidenced by fowlers position. saturation of position provided. RR- 32/min
increased patient.
Objective Data sputum
production.
-Increased sputum -instruct and -to maintain -deep breathing
production demonstrate deep- patent exercise instructed
-Respiratory Rate: breathing exercise. airway. and demonstrated
32/min
-ineffective cough
-use of accessory -Administer steam -to liquify -steam inhalation
function inhalation drugs as respiratory administered as per
per doctor’s order. secretions doctor’s order

- Administer - to liquify -nebulization with

nebulization drugs respiratory administered as per
as per doctor’s order secretions doctor’s order.

-perform chest - to liquify -chest

physiotherapy with respiratory physiotherapy
physiotherapist. secretions performed with
physiotherapist
Assessment Nursing Diagnosis Goal/ Intervention Rationale Implementatio Evaluation
Planning n
Subjective data: Hyperthermia related to reduce fever -assess the -to get base -Patient Fever
to inflammatory and maintain condition of line data of condition was reduced to
patient process as evidence normal patient. the patient. assessed. some
verbalized she is by temp-38.60 C, temperature T- 38.60 C extent.
having high TLC- raised temp-
fever. -provide tepid -to reduce -tepid sponge 37.60C.
sponge bath to temperature bath and
the patient. of the patient. compressions
provided.

Objective data: -provide Intra -hydration -IVF RL 500ML

-body venous fluids to reduces @80/hr.
temperature the patient. temperature. administered as
38.60C per doctor’s
-warm, flushed order.
skin -administer -reduce
antipyretic as temperature -inj pcm 1gm IV
per doctor’s by action on administered as
order. central per doctor’s
nervous order.
system
-Inj. Monocef
-administer anti- -to control 2gm and Inj
biotic as per spread of azithromycin
doctor’s order infection. 500mg
administered as
per doctor’s
order.
Assessment Nursing Goal/ Intervention Rationale Implementation Evaluation
Diagnosis Planning
Subjective Self-care deficit To meet -Assess the condition -to get the base line - patient condition Hygienic
Data: related to hygienic of the patient. data of the patient. was assessed, and daily
weakness and and daily patient is weak and needs of the
patient decreased and needs of the cannot met her patient met.
verbalized she endurance and patient daily needs. patient is
is feeling so loss of -Provide oral care to -to maintain oral comfortable
-oral care provided
weak to meet coordination as the patient. hygiene to patient.
to some
her daily needs evidence by extent.
inability to
perform her -Provide tepid bath to -to maintain and -tepid sponge
daily hygienic the patient. meet hygiene and provided.
practice. daily needs of the
patient.
Objective data:
-provide 2hourly -to avoid bed sores -2hourly position
-Patient is position to the patient. provided
feeling weak
-active passive
-inability to -provide active and -to promote blood exercise performed
stand without passive exercise. flow and promote
support ambulation.
-family was taught
-educate family to -to make family and involved to
perform basic needs of learn to perform perform basic
the patient. basic needs of needs of the family
patient.