Assessment

Subjective:
Ubo ng ubo
ang apo ko
na may
kasama na
plema.
Verbalized by
companion
Objective:
-cough with
sputum
production
(green
discharge)
-

Diagnosis
Ineffective
airway
clearance
related to
increased
sputum
production as
evidenced by
productive
cough
Definition:
Inability to
clear secretions
or obstructions
from the
respiratory
tract to
maintain a
clear airway

Planning
Short term:
After an hour
of nursing
intervention,
client will be
able to
expectorate
secretions
readily
Long term:
After 8 hours
of
intervention,
client will be
able to
maintain
airway
patency

Intervention
Independent:
-Rapport were
established
-Vital signs were
assessed
-Assessed rate of
respirations and
chest movement
-lungs were
auscultated
-advised
companion to
increased oral
fluid intake of
client
-Advised client to
perform frequent
deep-breathing
exercises
Dependent:
-Administered
IVF
-Performed
nebulization
treatment

Rationale
-To establish trust and
compliance
-To provide a baseline date
-tachypnea, shallow respirations,
and asymmetric chest
movement are frequently
present because of discomfort of
moving chest wall
-crackles, rhonchi, and wheezes
are heard on inspiration or
expiration in response to thick
secretions and airway
obstruction
-aids in mobilization and
expectoration of secretions
-provides maximum lung
expansion

-Aids in replenishing losses and

helps remove secretions
-Facilitates liquefaction and
removal of secretions

Evaluation
Short term:
After an hour, client
was able to
expectorate
secretions
Long term:
After 8 hours of
intervention, client
was able to maintain
proper airway
patency with breath
sounds clearing

-Administer
medications as
indicated

Assessment

Diagnosis

Planning

-aids in reduction of
bronchospasm and mobilization
of secretions

Intervention

Rationale

Evaluation

Subjective:
Mga ilan araw na siya
na mahina o minsan
walang gana kumain.
Verbalized by
companion
Objective:
-a decreased of body
weight from 16kg to
13kg in a span of 3
days
- A BMI of 9.3
(underweight)

Imbalanced
nutrition: less
than body
requirements
Defintion:
Intake of
nutrients
insufficient to
meet metabolic
needs

Short term:
After 1 day of
nursing
intervention,
client will
demonstrate an
increase in
appetite

Independent:
-Assessed clients
ability to swallow,
chew, and taste
food

-it can affect

ingestion and/or
digestion of
nutrients

-Assessed weight

-to establish
baseline
parameters

Long term:
After 3 days of
nursing
intervention,
client will regain
ideal body weight

-Noted age, body

build, strength,
activity, and rest
level

-helps determine
nutritional needs

-Encouraged
companion to
choose food that
is appealing for
the client

-to stimulate
appetite

-advised
companion to
avoid feeding
client foods that
causes
intolerances such
as spicy food

-to avoid GI
irritation

Dependent:
-Administered IVF

-To aid in
nutrition

Short term:
After a day of
intervention, client
was able to
demonstrate an
increase in appetite
Long term:
After 3 days of
nursing intervention,
client has shown
signs of increased
body weight but he is
still has not met the
ideal weight
appropriate for his
age and height. Goal
not met

Assessment
Not applicable;
presence of signs
and symptoms
establishes an actual
diagnosis

Diagnosis
Risk for infection
Definition: at
increased risk for
being invaded by
pathogenic
organisms

Planning

Intervention

Short term:
After an hour of
intervention, the
companion of
client will
verbalize
understanding
of individual
causative or risk
factors

Independent:
-Vitals were
monitored

Long term:
After 3 days of
nursing
intervention,
client will
achieve timely
healing to
prevent
secondary
infection

-Encouraged
adequate rest
balanced with
moderate activity

-Performed good
hand washing
techniques

Dependent:
-Administered
medications as
indicated
(Cefuroxime)

Rationale

Evaluation

-To provide
baseline and
during this period
of time,
complications
may develop

Short term:
After an hour of
nursing intervention,
clients companion
was able to verbalize
understating of risk
factors

-reduces spread
or acquisition of
microorganism
-facilitates
healing process
and enhances
natural
resistance

-to combat most

of the microbial
pneumonias

Long term:
After three days of
nursing intervention,
client shows progress
of healing but has
not achieved
optimum wellness.
Goal was partially
met