PHINMA University of Pangasinan

College of Health Sciences

Patient’s Initials: J.D.C Age & Gender: Male Chief Complaint: shortness of breath Name of Student Nurse: Fonbuena, Kate Ashley C.
Birthday: _______________________ Admitting Diagnosis: Pneumonia Level/block/group: BSN1 - 12
Address: ________________________ Hospital/area: ________________________________
Date of Confinement: March 20, 2023 Clinical Instructor: ________________ Date: _______

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

An inflammation of the Short-term Goals: Independent Interventions: Independent Interventions: Short-term Goal:
Subjective: lung parenchyma After 24 hours of nursing 1. Assist the patient in positioning 1. Assisting the patient in After 24 hours of nursing
“nahihirapan ako associated with alveolar intervention, the patient will and providing pursed-lip positioning and providing pursed- intervention, the patient
huminga” edema and congestion be able to: breathing and coughing lip breathing and coughing was able to:
as verbalized by the that impair gas 1. The patient will maintain a techniques to maintain airway techniques to maintain airway 1. The patient maintained a
patient. exchange. Pneumonia is patent airway patency. patency helps to ensure that the patent airway
caused by a bacterial or 2. The patient will patient’s airway remains open 2. The patient
Objective: viral infection spread by demonstrate improved lung and clear. demonstrated improved
BT- 38.5˚c droplets or by sounds and ventilation on lung sounds and ventilation
HR- 114 bpm contact and is the sixth auscultation 2. Monitor and assess the 2. Monitoring and assessing the on auscultation
BP- 110/70 mmHg leading cause of death. 3. The patient will patient’s respiratory rate, oxygen patient’s respiratory rate, oxygen 3. The patient
RR- 28 bpm demonstrate improved saturation level, and lung sounds saturation level, and lung sounds demonstrated improved
breathing pattern and at least every 4 hours. at least every 4 hours allows for breathing pattern and
Diaphoretic oxygen saturation levels early detection of any changes in oxygen saturation levels
NURSING DIAGNOSIS the patient’s condition.
Risk for Impaired Gas Long-term Goals: Long-term Goal:
Exchange related to After 1-2 weeks of nursing 3. Monitor for signs of 3. Monitoring for signs of After 1-2 weeks of nursing
reduced ventilatory intervention, the patient will complications such as pleurisy, complications such as pleurisy, intervention, the patient
capacity and increased be able to: respiratory distress, and acute respiratory distress, and acute was able to:
oxygen demand as 1. The patient will respiratory failure. respiratory failure allows for early 1. The patient
evidenced by decreased demonstrate full resolution detection and intervention. demonstrated full
oxygen saturation levels of pneumonia symptoms resolution of pneumonia
and increased respiratory 4. Monitor for signs and 4. Monitoring for signs and symptoms
rate. 2. The patient will be free of symptoms of recurrence. symptoms of recurrence allows 2. The patient was free of
complications and have for early detection and complications and had
normal oxygen saturation intervention. normal oxygen saturation
levels at discharge. levels at discharge.
3. The patient will 3. The patient
demonstrate improved demonstrated improved
knowledge of self-care Dependent Interventions:
measures and medications 1. Administer prescribed
to prevent recurrence of medications as ordered and as
pneumonia symptoms. needed for symptom
management.
2. Educate patient and family
about the disease process,
medications, and self-care
measures.
Collaborative Interventions:
1. Work with other healthcare
providers to develop an
individualized plan of care.
2. Refer patient to pulmonary
rehabilitation as needed.
Dependent Interventions: knowledge of self-care
1. Administering prescribed measures and medications
medications as ordered and as to prevent recurrence of
needed for symptom pneumonia symptoms.
management helps control
symptoms and prevent
complications.
2. Educating patient and family
about the disease process,
medications, and self-care
measures helps the patient and
their family to understand the
disease and how to manage it.
Collaborative Interventions:
1. Working with other healthcare
providers to develop an
individualized plan of care.
2. Referring patient to pulmonary
rehabilitation as needed helps to
ensure that the patient is
receiving all the necessary care
and support, they need.
ASSESSMENT EXPLANATION OF THE PLANNING INTERVENTIONS RATIONALE EVALUATION
PROBLEM