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Patients name: L.M.S.C

Hospital No: 2015818230

Age: 2 years old

Room No. Bed no1

Diagnosis: Pneumonia Severe

Physician: Dr. Abao, Mary Jane

Nurses Name and Signature: Angeles, Kristine Mae

PATIENTS OUTCOME CRITERIA
As soon as the patient will be discharged from
the hospital, the patient and significant others
will be able to:

NURSING ORDERS

ASSESSMENT
1. Assess any signs and symptoms of
infection.
2. Assess clients and significant others
perception on importance of proper
hygiene.

3. Assess proper proper diet and nutrition.

PLANNING
1. Plan for any recreational activities for
the patient.

Instruct patient to go to the nearest

hospitals if signs and symptoms of
infections occur such as: redness,
tenderness in the breast and purulent
discharges.
Encourage client to do proper hygiene
to
prevent
contamination
of
microorganisms that will cause
infection.
Encourage patient to eat variety of
healthy foods to combat diseases.

Diversion of activity or attention of

pediatric patient should be practice of
his family to promote cooperation in
the course of therapy.

2. Plan of retime visit.

Encourage patient to have a return

visit for monitoring its health and any
unpleasant circumstances.

3. Encourage enough nap.

Instruct to have at least 8 hours of

sleep to promote immune system and
for relaxation of body.

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4. Plan in place to meet the needs after

discharge.

A plan to promote life and health

should be told by the significant
others.

IMPLEMENTATION
M- The patient will take the prescribe
medications regularly.

Instruct the patient to take medication

as prescribed and do not stop even if
feel better.

E- Provide comfortable environment.

Instruct the patient and significant

others to maintain cleanliness of her
environment to promote fast recovery.
Encourage patient and significant
others that immunization, deworming
and having dental check-up are one of
the tool to combat and avoid worsen
diseases.

T- Treatment:
Immunization
Deworming
Dental check-up
H Health Teaching:
Hand washing
Bathing
Nail cutting

Teach client effective hand washing

and bathing that promotes a healthy
life and gives relaxation also nail
cutting
avoid
transmission
of
microorganisms.

O- seek out patient referral or access to Brgy.

Health centers

Advice patient and significant others

to have a follow up check up for his
additional assistance.

D-have a balanced and regular diet

S- maintain spirituality

Instruct patient to eat healthy foods

such fresh fruits, vegetables and foods
that lots of vitamins and necessary
nutrients.

EVALUATION

Advice patient to continue his spiritual

activities to promote spiritual wellbeing.

Evaluate the patient and significant others

in understanding to health teaching and
discharge instruction given.

Encourages patient to verbalize

understanding or the things taught to
him for this will help in her recovery.

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Ask the significant others to test if

they listens and gain knowledge.