Assessment Diagnosis Plan of Care Interventions Rationale Evaluation

Objective: Ineffective After 1 hour of Independent After 1 hour of

Fever, Airway nursing nursing
shortness of Clearance interventions, interventions,
breath, secondary to the patient’s 1.) Perform 1.) To mobilize the patient’s
tachypnea, Excess RR will chest mucus RR will
reduced O2 Production of decrease from physiotherapy. secretions in decrease from
saturation, Mucous a 28 to a 20. airways for a 28 to a 20.
ground glass Secretions in easy
appearance of Airways as expectoration.
chest x-ray, manifested by
refractive Ground Glass
hypoxemia Appearance of 2.) Encourage 2.) To
Chest X- Ray deep maximize
breathing and effort during
coughing expectoration.
exercises.

3.) Position
3.) To promote
the client in
maximum lung
Semi Fowler’s
expansion.
Position.

Dependent:

1.) Assist in
the 1.) To promote
installation of gas exchange
CPAP machine and lung
and maintain expansion.
at +10 cm
H2O, 100%
humidified
oxygen and
FIO2 at 50%.

2.) Administer
Erythromycin
and Acyclovir
 as ordered.

2.) To inhibit
viral
polymerization
Collaborative and cell wall
synthesis.

1.) Instruct
family to keep
the patient’s
surrounding
clean and 1.) To reduce
allergen free. the risk of
pathogen
accumulation
in
surroundings
and to prevent
mucus
secretion in
response to
allergens.

Assessment Diagnosis Plan of Care Interventions Rationale Evaluation

Objective: Impaired Skin After 2 hours Independent: After 2 hours
Rash Integrity of nursing of nursing
1.) Instruct the 1.) To reduce
consisting of related to interventions, interventions,
patient to irritation on
vesicles, fever Formation of the patient the patient
wear thin, and skin
Tzank Cells as will display displayed
soft clothes.
manifested by timely healing timely healing
Tiny Vesicular of vesicular of vesicular
Lesions in Skin lesions. lesions.
2.) Keep
2.) To prevent
wounds clean
irritation.
and dry.

3.) To prevent
3.) Instruct the
extension of
client from
trauma.
scratching on
vesicles.
Instead, apply
 ice to itchy
areas of skin.

1.) To inhibit
Dependent further
infection of
skin
1.) Administer
Acyclovir and
Erythromycin
as ordered by
2.) For rapid
physician.
wound healing

2.) Refer to
Dermatologist.

1.) Heat
Collaborative
increases
irritations

1.) Instruct the

family to keep
environment
at home cool
and dry.

Assessment Diagnosis Plan of Care Interventions Rationale Evaluation

Objective: Risk for After 2 hours Independent: After 2 hours
Rash Extension of of nursing of nursing
consisting of Skin Trauma interventions, interventions,
vesicles, Fever related to the patient 1.) Instruct the 1.) To prevent the patient
Exposure of will display patient to abrading skin displayed early
Skin Blisters early keep her recognition of
recognition of fingernails risk for skin
risk for skin clean and trauma and
trauma and short. allow for
allow for prompt
prompt 2.) To treatment.
treatment. 2.) Teach to decrease risk
very gently pat for skin
the skin
instead of abrasion
scratching
when itchy.

1.) For faster

Dependent
healing of
1.) Refer to broken skin
Dermatologist.

2.) To help
2.) Administer heal wounds
Aciclovir and faster.
Erythromycin
as ordered by
physician.

Collaborative

1.) To
minimize the
1.) Keep the
patient’s
patient’s
exposure to
environment
irritants/
clean and dry.
allergens.