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  • Assessment Diagnosis Planning Intervention Rationale Evaluation

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    Justine Mae A. Loria
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    The patient presented with difficulty breathing and mucus secretion. After 2 hours of nursing intervention including assessment, monitoring, positioning changes, deep breathing exercises, coughing, percussion, oxygen therapy, and medication administration; the goal of eased breathing and less mucus was met. Evaluation of vital signs, ABG, and pulse oximetry will continue to monitor the patient's progress.

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    NCP Pnuuemonia

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    The patient presented with difficulty breathing and mucus secretion. After 2 hours of nursing intervention including assessment, monitoring, positioning changes, deep breathing exercises, coughing, percussion, oxygen therapy, and medication administration; the goal of eased breathing and less mucus was met. Evaluation of vital signs, ABG, and pulse oximetry will continue to monitor the patient's progress.

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    163 views2 pages

    Assessment Diagnosis Planning Intervention Rationale Evaluation

    Uploaded by

    Justine Mae A. Loria
    The patient presented with difficulty breathing and mucus secretion. After 2 hours of nursing intervention including assessment, monitoring, positioning changes, deep breathing exercises, coughing, percussion, oxygen therapy, and medication administration; the goal of eased breathing and less mucus was met. Evaluation of vital signs, ABG, and pulse oximetry will continue to monitor the patient's progress.

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    © All Rights Reserved
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    of 2

    Assessment Diagnosis Planning Intervention Rationale Evaluation

    Subjective data: Impaired gas After 2 hours of Independent intervention Goal met
    “Nahihirapan po exchange related to nursing intervention
    akong huminga” collection of mucus the patient will
    As verbalized by in the airway as demonstrate ease Established rapport For nurse patient interaction
    the patient evidence by of breathing, less
    difficulty of presence of mucus Assessed, monitored, To obtain baseline data and for
    Objetive data: breathing secretion, absence documented vital signs comparison of previous data to be
    Presence of use of accessory assessed in patient vital sign
    mucus secretion muscle and normal Assessed, patient skin To note for cyanosis
    Use of accessory respiration.
    muscle, Assessed patient level of Restlessness, irritation, confusion,
    Deep and shallow consciousness, mental status. and somnolence may indicate
    respiration hypoxemia and decreased
    Irritated/ cerebral oxygenation and require
    BP: 120/80mmhg further intervention
    PR: 98bpm
    RR: 22cpm Monitored ABG and Pulse It follows the progress of the
    HR: 100bpm oximetry. disease process and facilitates
    Temp: 37.2 alterations in pulmonary therapy.
    Pulse oximetry detects changes in
    oxygenation. O2 sats should be at
    90% or greater.

    Elevate the head of the bed and These measures promote


    encouraged frequent position maximum chest expansion,
    changes, deep breathing, and mobilize secretions and improve
    effective coughing. ventilation

    Performed chest percussion. To loosen secretion

    To loosen secretion
    Encouraged to drink 2 liters of
    water if not contraindicated

    Dependent Intervention the purpose of oxygen therapy is


    Administer oxygen therapy by to maintain PaO2 above 60
    appropriate means: nasal prongs, mmHg. Oxygen is administered by
    mask, Venturi mask. the method that provides
    appropriate delivery within the
    patient’s tolerance. Note: Patients
    with underlying chronic lung
    diseases should be given oxygen
    cautiously.

    To achieve desired therapeutic


    Administer medication as management in patient condition.
    prescribed

    Collaborative
    To address the proper diet needed
    by the patient
    Collaborate with hospital’s
    dietician

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