Assessment Nursing Planning Nursing Nursing Theories Evaluation

Diagnosis Intervention
Virginia Henderson’s
Subjective data “ Mainit Altered After the nursing Independent 14 Basic Needs Goal partially met:
thermoregulation 1.) vital signs every The client’s temperature
intervention the client
siya ” as claimed by the Maintaining normal
r/t bacterial infection. will maintain the two hours was stable at 37.8C after
mother normal and stable especially the body temperature by
the appropriate nursing
body temperature of temperature. adjusting clothing and
intervention.
Objective data: modifying the
36- 37 C.
 Temperature environment.
Vital signs is a reference to
38. 8 C
(Nov 3 at 12 noon) determine the client
condition.
 Temperature
36.8 C 2.) Advise the Eating and drinking
(Nov 3 at 6 pm)
mother to adequately.
 Temperature increase the fluid
39.3 C intake.
(Nov 4 at 12 am) Faye Glenn Abdellah’s
One way of promoting heat 21 typology nursing
 Skin warm to
touch loss and to assess problems
hydration.
To maintain good
3.) Initiate Tepid hygiene and physical
sponge bath comfort.
To reduce body
temperature.
 4.) Administer
Paracetamol Faye Glenn Abdellah’s
(Tempra) 21 typology nursing
120mg/5ml for
problems
fever by nurse on
duty.
To promote safety
To reduce the body
temperature of the client through prevention of
accident, injury or other
trauma through
prevention of the spread
of infection
 Assessment Nursing Planning Nursing Nursing Theories Evaluation
Diagnosis Intervention
Subjective data “ Gainubo Ineffective airway After the nursing Goal met:
clearance r/t retained intervention the patient Independent:
siya as verbalized by the Faye Glenn Abadellah’s The patients respiration
secretions secondary to will achieve normal 1.) Assess the rate and
pneumonia. respiration from 56 depth of respiration 21 nursing problems. rate decreased from 56
mother”
bpm to 30-40 bpm. and chest movement. bpm to 40 bpm after
Objective data: To facilitate the nursing intervention.
Tachypnea, shallow maintenance of a
 CxR- PAL view
respirations are frequently supply of oxygen to all
Impression: Left present because of body cells
discomfort of moving chest
Bilateral Pneumonia wall or fluid in lungs.
 (+) Rhonchi sound
2.) Position the patient
upon auscultation in an upright
position. To maintain good
 RR- 56 bpm
hygiene and physical
(Tachypnea) Doing so would lower the comfort
diaphragm and promote
chest expansion.

3.) Encourage increase

oral fluid intake. Virginia Henderson’s
14 basic needs
Fluids help minimize
mucosal drying and
maximizing axillary action
 to move secretions.
Eating and drinking
adequately

Assessment Nursing Planning Nursing Nursing Theories Evaluation

Diagnosis Intervention
Subjective data: Imbalanced nutrition: After 4 days of Independent: Faye Glenn Abadellah’s Goal partially met:
1.) Evaluate the 21 nursing problems. After the appropriate nursing
“Wala siya gakaon utan less intervention the patient
daily food intake. intervention
kag gamay lang iya as Than the body will be able to gain weight The client starts to intake an
verbalized by the mother. requirement r/t from 8.1kg to 9kg. To facilitate the adequate amount of
To reveal possible cause
maintenance of nutrition nutrients.
decreased oral intake and of malnutrition change
of all body cells.
that could be made in
Objective data: absorption of nutritients. The client will be able
patient’s intake.
 Hemoglobin take adequate amount of
2.) Encourage
65gms/L nutrients. Dorothea Orem
balance diet Self-care deficit theory of
(115-155)
nursing.
emphasizing high
 Hematocrit
protein and high Maintain of a sufficient
0.25 vol(fr)
intake of food.
carbohydrate diet.
(0.34- 0.40)
 BMI:
To assess metabolic and
12.5
nutrition needs of the
(18-25)
patient.

Assessment Nursing Planning Nursing Nursing Theories Evaluation

Diagnosis Intervention
Subjective data: Altered tissue perfusion After the appropriate Independent: Faye Glenn Abdellah’s Goal met:
“Nagpanglupsi sa” as 1.) Assess and “21 Typology of nursing
related to insufficient nursing intervention the
verbalized by the mother monitor vital signs. problems” The hemoglobin and
hemoglobin and client will attain the hematocrit of the client
Objective data: Provides information increased to the normal range
hematocrit normal range of 115-155 To recognize the
about the adequacy of after the appropriate nursing
 Hemoglobin hemoglobin and normal tissue perfusion and help physiological responses intervention.
and to determine the
65gms/L range of 0.34-0.40 of of the body to disease
condition of the client. Hemoglobin increased
(115-155) hematocrit. conditions- pathological, from 65 gms/L to
126 gms/L
 Hematocrit physiological and
0.24 vol(fr) compensatory. Hematocrit increased from
0.24 vol(fr) to 0.40 vol(fr)
(0.34-0.40)
 MCV 2.) Administer folic The Client also undergone 2
To facilitate the
Blood transfusion.
54 fl acid (folate) syrup maintenance of nutrition
of all body cells.
(75- 87) of 5ml OD as a
 MCH vitamin
14 pg supplement for
(24-30) anemia by the
 MCHC nurse on duty as
27 g/dL ordered by the
(32-36) doctor.
 Pale skin Folic acid is a supplement
(Pallor) that could help the client
to have a normal RBC