Assessment Nursing Scientific Planning Nursing Rationale

Diagnosis Explanation Intervention

S= patient may Activity The onset of Short Term : > Obtain subjective >Helps to determi
verbalize Intolerance pneumonia is data from patient effects of pneumo
“magkasakit ku related to generally marked by After 4 hours regarding normal the patient’s abilit
mangisnawa increased fever, dyspnea, and of Nursing activities prior to active.
ampo mimingal oxygen shortness of breath Interventions, onset of pneumonia;
ku gan demand with and easy fatigability the patient is monitor for labored
maglakad activity and that may lead to able to perform breathing, fatigue and >If increased phys
kumu.” hypoxia (lack inability to perform activities of exhaustion. activity causes sho
of oxygen activities of daily daily living of breath, activity
O=Patient supply with living. without > Reduce level of be reduced until
Manifested the oxygen shortness of activity as required in oxygenation is ade
following : demand) Due to the breath such as response to shortness
accumulation of thick doing personal of breath.
> appears weak tenacious mucous in hygiene, etc. > Conserves energ
the alveoli altering reduces oxygen de
> poor skin gas exchange > Assist with patients with pneu
turgor ( oxygen and carbon activities as needed. lack enough oxyge
dioxide) between the reserves to perform
>pale nail beds alveoli And Long Term : activities independ
>Pace activities and
After 24 hours encourage periods of >It conserves ener
> easy of Nursing rest and activity
fatigability Interventions, during the day.
the patient > Use the result to
states that he is indicate when the
> non- comfortable may be increased
productive with activity > Monitor VS and decreased.
cough performance oxygen saturation
and shortness before and after > Activities should
>shortness of of breath is activity. increased graduall
breath during improved tolerated, to avoid
activities following taxing the patient.
cessation of > Gradually increase
> RR of 38 activity, and activity as tolerated
cpm, with the patient’s and share guidelines > Physical activit
shallow, rapid RR returns to for progression with increases enduranc
breathing baseline within patient. stamina; following
5 minutes. pneumonia, return
normal activity ma
Patient may > Discuss with the time.
manifest the patients activities that
following : would be appropriate
once at home that > This indicate
>Inability to would be within the intolerance to activ
perform
patient’s activity the level of activit
physical
activities tolerance. should be evaluate

> level I
functional level
classification
( walk, regular > Inform the patient > Iron has a role in
phase, on level
to stop any activity oxygen transport a
indefinitely;
one flight or that produces increases energy le
more but more
shortness of breath.
shortness of
breath than >To prevent injuri
normal)
> Encourage intake
>labored of foods high in iron >Improves oxygen
breathing
and good source of and provides oxyg
>physical energy such as lean reserves to be used
exhaustion
meat, legumes which increased demand
>oxygen are rich in protein.
saturation less
than 90%


> Assist patient to
learn and demonstrate
appropriate safety
measures.
> Have the patient
use oxygen
immediately prior to
activity in the acute
setting, as ordered.