ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVAUATION

SUBJECTIVE: “Hindi na Auscultate lungs for It helps to determine areas of good Short term:
ako masyado air movement and air exchange. Manifestations of At the end of
nakakakilos simula Activity Short term: abnormal breath respiratory distress are indicative my shift patient
nung nagkasakit ako. Intolerance Patient will sounds. Note of the degree of lung involvement was able to
Hindi ako masyado due to demonstrate respiratory rate, and underlying general health sleep and rest
nakakatulog”,as exhaustion relaxed manner, depth, and ease of status as patients will adapt their adequately. She
verbalized by the associated resting/sleeping respiration. breathing patterns to facilitate was able to
patient with and engaging in effective gas exchange. perform deep
interruption activity breathing and
OBJECTIVE: in appropriately. Assess cough Coughing is the most effective way coughing
(+) exertional dyspnea usual sleep effectiveness and to remove secretions. Pneumonia exercises and
(+) crackles on left pattern Long term: The productivity may cause thick and tenacious showed
field because of patient will secretions to patients. improvement in
(+) persistent discomfort demonstrate a Assess patient respiration
productive cough with and measurable response to activity. Extra activity can worsen after
whitish sputum excessive increase in Encourage rest shortness of breath. Ensure the maximizing her
(+) tachypnea 105 coughing tolerance to periods and limit patient rests between strenuous time to rest.
bpm activity with activities to patient activities.
(+) general weakness absence of tolerance. RR: 26
(+) Jackson-Pratt drain dyspnea and
on the Right excessive Assist patient to Patient may be comfortable with PR: 98
fatigue, and vital assume comfortable head of bed elevated because it;
signs within position for rest enhances lung expansion and BP: 110/70
normal range. and sleep. ventilation. Appropriate sleep
promotes healing. Long term:
Encourage and Deep breathing
The patient
assist with deep- exercises facilitates maximum
verbalized
breathing exercises lung expansion and improves the
understanding
and pursed-lip productivity of cough. This method
of the
breathing as relaxes muscles and increases the
importance of
appropriate. patient’s oxygen level. Coughing
rest in
and deep breathing encourages
treatment plan
expectoration, which enables
and necessity
better gas exchange
for balancing
activities with
Provide a quiet Reduces stress and excess
rest. Patient
environment and stimulation, promoting rest. Extra
was able to
limit visitors during activity can worsen shortness of
perform self-
 breath. Ensure the patient rests
acute phase as between strenuous activities. care activities
indicated. with minimum
assistance
Assist with self- while vital signs
care activities as Minimizes exhaustion and helps within normal
necessary. balance oxygen supply and range.
demand.
Teach patient about
performing
relaxation Effective coughing may exhaust an
techniques and already compromised patient.
scheduling activities Fatigue may be a contributing
to avoid fatigue and factor to ineffective coughing.
provide for rest Bedrest is encouraged to decrease
periods. metabolic demands, thus
conserving energy for healing.