ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Infective airway As a result of a At the end of the 8- Assist patient deep Deep breathing After the 8-hour
clearance related to secondary lung hour nurse-patient breating exercise. facilitates maximum intervention, the
excessive mucus infection, Mrs. interaction, the expansion of the patient was able to
production to Smith is patient be able to lungs and smaller maintain clear, open
secondary lung experiencing maintain clear, open airways. airways, as
infection. excessive mucus. airways, as To establish evidenced by
Based on her evidenced by Monitor vital signs. baseline data and normal breath,
clinical normal breath, monitor changes. normal rate and
presentation, she normal rate and depth of
experienced a depth of respirations, and
To measure the
productive cough respirations, and ability to effectively
amount of oxygen
and a greenish ability to effectively cough p secretions
in the blood to
spatum; these are cough p secretions after treatments
determine lung
the symptoms of after treatments and deep breathing
function
pneumonia. and deep breathing. Monitor ABGs and
pulse oximetry To prevent fatigue.
Pneumonia is an
Demonstrate To take advantage Demonstrated
excess of fluid in
improved of gravity- improved
the lungs resulting
ventilation and Encourage rest and decreasing pressure ventilation and
from an
oxygenation of limit activity on the diaphragm oxygenation of
inflammation.
tissues by ABGs and enhance tissues by ABGs
The inflamation is drainage.
within client’s within client’s
triggered by many
acceptable range Elevated head of Fluid, especially acceptable range
infectious
and absence of the bed/ change warm liquid, aids in and absence of
organisms and by
symptoms of position frequently mobilization and symptoms of
the inhalation of
respiratory distress. anticipation of respiratory distress.
irrating ageants.
secration.

Increase fluid intake

2,OOO ml/day