ASSESMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

OBJECTIVE: Bronchopneumoni Short term goal: Independent: After 8 hours

 Difficulty a Slightly pale and of nursing
breathing has high tendency After 8hours of  Encourage deep intervention,
 Lethargy to fall asleep. nursing breathing exercise goal partially
 Productive Ineffective Airway intervention.  Increase fluid intake as met. The
cough Clearance related Secretions will appropriate patient was
 Anorexia to increased be mobilized,  Monitor rate, rhythm, able to
 Altered level production of airway patency depth and effort of >demonstrate
of respiratory will be respirations. coughing and
consciousness secretions maintained free  Assist patient into deep
 On and of of secretions as moderate high back breathing
fever evidence rest position exercise
 VS taken as patient’s ability  Auscultate lung fields, every 1-2
follows: to effectively noting area=s of hours during
T: 37.3 cough outu decreased of absent day
RR: 42 cpm secretions, clear airflow and
PR:136 bpm lung sounds and adventitious breath
uncompromised sounds
respiratory rate. Dependent:
 Administer
ordered
medications such
as mucolytic
agents,
bronchodilators,
expectorants
 Administer
nebulizations as
needed
MARY ROSE M. BAINGIT BSN II-GMN
NCP FOR BRONCHOPNEUMONIA