ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective airway Short Term: Monitor rate, rhythm, Provides a basis for Short Term:
clearance related to thick After 8 hours of nursing depth, and effort of evaluating adequacy of After 8 hours of nursing
“Ilang araw na syang sputum secondary to interventions, the patient respirations. ventilation. interventions, the patient
inuubo at nahihirapang pneumonia as evidenced will be able to was able to
huminga,” as verbalized by adventitious expectorate/clear Note chest movements, Presence of nasal flaring expectorate/clear
by the relative of the breath sounds and thick secretions readily. watch for symmetry, use and use of accessory secretions readily.
patient. yellow sputum. of accessory muscles of respirations
Long Term: muscles, and may occur in response to Long Term:
Objective: Pneumonia is an After 1 week of nursing supraclavicular and ineffective ventilation. After 1 week of nursing
 O2 sat: 80% inflammation of the lung interventions, the patient intercostal muscle interventions, the patient
 With O2 at parenchyma, associated will be able to maintain retractions. was able to maintain
2LPM via nasal with alveolar edema and airway patency by airway patency by
cannula congestion that impair showing: Elevate head of the To take advantage of showing:
 Respirations: gas exchange. bed/change position gravity decreasing
24breaths/min a. Normal breath every 2hours and prn pressure on the a. Normal breath
 Chronically bed sounds when diaphragm and sounds when
ridden auscultated enhancing drainage auscultated
 81 y/o b. Respiratory rate of/ventilation to different b. Respiratory rate
 Skin is pale and of 16-20 lung segments. of 16-20
cool to touch breaths/min breaths/min
 Use of accessory c. Not using Promote systemic fluid Adequate fluid intake c. Not using
muscles when accessory hydration, as enhances liquefaction of accessory
breathing muscles when appropriate. pulmonary secretions muscles when
 Inspiratory breathing and facilitates breathing
crackles with expectoration of mucus.
diminished
breath sounds Oral suction prn. To clear out secretions
when when it blocks the
auscultated airway.
 Thick yellow
sputum is Auscultate lung sounds Assists in evaluating
present during after treatments to note prescribed treatments
suctioning results. and client outcomes.

Institute respiratory A variety of respiratory

Subjective: Activity intolerance Short Term: Evaluate patient’s Establishes patient’s Short Term:
related to exhaustion After 8 hours of nursing response to activity. Note capabilities/needs and After 8 hours of nursing
Patient’s relative stated, associated with interventions, the patient reports of dyspnea, facilitates choice of interventions, the patient
“lalo syang nanghina interruption in usual will be able to report a increased weakness/ interventions. was able to report a
nung magkaubo.” sleep pattern because of measurable increase in fatigue, and changes in measurable increase in
discomfort, excessive tolerance to activity with vital signs during and tolerance to activity with
coughing, and dyspnea as absence of dyspnea and after activities. absence of dyspnea and
Objective: evidenced by verbal excessive fatigue, and excessive fatigue, and
 O2 sat: 80% reports. vital signs within Provide a quiet Reduces stress and vital signs within
 With O2 at patient’s acceptable environment and limit excess stimulation, patient’s acceptable
2LPM via nasal Definition: Insufficient range. visitors. promoting rest. range.
cannula physiological or
 Respirations: psychological energy to Long Term: Explain importance of Bed rest is maintained Long Term:
24breaths/min endure or complete After 1 week of nursing rest in treatment plan during acute phase to After 1 week of nursing
 Chronically bed required or desired daily interventions, the patient and necessity for decrease metabolic interventions, the patient
ridden activities will be able demonstrate balancing activities with demands, thus was able demonstrate a
 81 y/o a measurable increase in rest. conserving energy for measurable increase in
 Skin is pale and tolerance to activity with healing. Activity tolerance to activity with
cool to touch absence of dyspnea and restrictions thereafter are absence of dyspnea and
 PEG excessive fatigue, and determined by individual excessive fatigue, and
 Iron supplement vital signs within patient response to vital signs within
medication patient’s acceptable activity and resolution of patient’s acceptable
range. respiratory insufficiency. range.

Patient may be
Assist patient to assume comfortable with head of
comfortable position for bed elevated, sleeping in
rest/ sleep. a chair, or leaning
forward on over bed
table with pillow support.

Minimizes exhaustion
Assist with self-care and helps balance oxygen
activities as necessary. supply and demand.
Provide for progressive
increase in activities
during recovery phase
and demand.