Trixie Ann C.

Salasibar
BSN 2B-2D

actual

ASSESMENT EXPLANATION OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

OF THE
PROBLEM
SUBJECTIVE: It is considered the Within 12 hours of  Assessed and o To detect early After 12 hours of
“mainit siya at state in which the effective nursing record O2 signs of effective nursing
parang nahihirapan rate, depth, timing, interventions, the saturation and respiratory interventions, the
huminga’ as and rhythm, or the patient: respiratory rate, distress patient had:
verbalized by the pattern of breathing - will be able depth, and - achieved
mother is altered. When the to have quality normal
breathing pattern is normal  Monitored for respiratory
OBJECTIVE: ineffective, the breathing use of o To be able to rate with
Vital signs: body is most likely pattern and accessory identify normal
CR:92 bpm not getting enough presence of muscles increased in breathing.
RR: 28 cpm oxygen to the cells. breathe. work of
Temp: 38.8 degree Increased capillary breathing by
Celsius permeability and  Observed for retraction
>observed vasodilation to nasal flaring
difficulty of provide adequate o Breathing may
breathing uses of perfusion, oxygen, increased as lung
accessory muscle. and nutrients to compliance
>presence of tissue and cells.
productive cough Imbalance of  Administered o Supplemental
and vomiting. inflammatory oxygen as oxygen helps
>unable to breathe response and organ ordered reduce
in supine position shutting down due hypoxemia and
to physiologic relieve
DIAGNOSIS: progression of respiratory
Ineffective infecting including distress
breathing pattern lungs. This may o to maximize lung
related to cause ineffective
 community breathing pattern  Positioned in expansion
acquired semi fowler o measure to allow
pneumonia patient to
 Instructed participate in
proper maintain health
breathing status and
techniques improve
ventilation
o this prevent
fatigue and
 Encourage to reduces oxygen
have rest demand
periods in o for patient to
between daily gain more
activities understanding
 Educated about the
regarding the treatment being
importance of given
compliance to
given
medication

Potential

ASSESSMENT EXPLANATION OF OBJECTIVES INTERVENTION RATIONALE EVALUATION

THE PROBLEM
OBJECTIVE: Possibly evidenced by Within 30mins-1hr,  Assess
Vital signs: risk factors of stasis of the patient will be immunization
CR:92 bpm body fluids, able to achieve status and
 RR: 28 cpm malnutrition and timely resolution of history
Temp: 38.8 degree associated condition of current infection
Celsius chronic illness, without
>observed difficulty decrease in ciliary complications
of breathing uses of action,
accessory muscle. immunosuppression
>presence of
productive cough SOURCE:
and vomiting. Doenges, M.,
>unable to breathe Moorhouse, M., &
in supine position Murr, A. Nurse's
pocket guide (p. 1005).
DIAGNOSIS:
Risk of infection
related to
community acquired
pneumonia

https://www.studocu.com/ph/document/university-of-the-cordilleras/health-assessment/potential-ncp-for-community-acquired-
pneumonia-df/12461271

Dx:
a. Check doctors order
b. Assess pain score
c. Assess history of
allergies
Tx:
a. Give drug with food,
milk or antacids
b. Do not increase or
double dose; follow
exactly as prescribed
and indicated
c. Discontinue drug
promptly if diarrhea.
Dark stools.
Hematemesis,
ecchymosis, epistaxis
or rash occur and do
not use again. Contact
physician
Edx:
a. Document accordingly
b. Monitor for adverse
effect
c. Instruct
discontinuation of
medication if adverse
effect occurs