Assessment Diagnosis Planning Intervention Ratio Evaluation

nale

Independent:

Subjective: Hyperthermia related to Goal: After 8 hours of nursing

inability or decreased interventions, the
ability to perspire as - Provide tepid sponge Enhances heat loss by patient’s temperature
manifested by the bath. evaporation & lowered down,
“Nanginginig na po ang After 4 hours of conduction.
kanyang katawan sa elevated body comprehensive nursing maintained vital signs at
sobrang lagnat.” as temperature. intervention, the patient a normal level and the
verbalized by the will: skin color changed from
mother of the patient. Increases metabolic flushed to a normal one.
- Maintain normal - Assess fluid loss & rate & diaphoresis. Goal was met.
temperature. facilitate oral intake.
- Maintain vital signs at
Objective: normal levels
Reduces body heat
- Be alert and - Promote bed rest.
 Body temperature responsive production.
of 39.9°C - Be comfortable in bed.
 Weakness
observed Dissipates heat by
- Provide cool convection.
 Flushed skin Desired Outcome: circulating air using a
fan.

The patient will gain the

Increases comfort.
normal body - Assist patient in
temperature and there changing into dry
will be resolution of clothing.
hyperthermia as
evidenced by the
normal skin color. - Provide oral hygiene.

Prevents herpetic
lesions of the mouth.

- Monitor vital signs.

Notes progress &
changes of condition.

Dependent:

- Maintain IV fluids as Prevents dehydration.

ordered by physician.

- Administer anti-pyretic
as ordered. Reduces fever.

Administer antibiotic as
ordered.
Treats underlying cause
Collaborative:

- Monitor hematologic
test & other pertinent
lab records. Indicates presence of
infection & dehydration.

- Discuss condition of
the patient with other
members of the health Ensures continuous
care team. intervention.
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Independent:

Subjective: Ineffective airway Goal: The most convenient way to After 3 hours of
clearance related to remove most secretions is nursing
retained secretions Teach the patient the proper coughing. So it is necessary to interventions, the
in the bronchi ways of coughing and assist the patient during this patient was able
“Nahihirapan na sya After 3 hours of breathing. (e.g., take a deep
huminga dahil sa secondary to comprehensive activity. Deep breathing, on the to maintain airway
pneumonia. breath, hold for 2 seconds, and other hand, promotes patency and clear
plema hindi nya nursing intervention,
cough two or three times in oxygenation before controlled breath sounds.
mailbas, grabe na the patient will be
able to maintain succession). coughing. Goal was met.
kasi ang ubo nya eh
clear, open airways
as evidence by
normal breath
.” as verbalized by Upright position limits
sounds, normal rate
the mother of the and depth of Position the patient upright if abdominal contents from
patient. respirations, and tolerated. Regularly check the pushing upward and inhibiting
ability to effectively patient’s position to prevent lung expansion. This position
cough up secretions sliding down in bed. promotes better lung
after treatments and expansion and improved air
deep breaths.. exchange.

Objective:
Desired Outcome: Understanding prescriptions
promote safe and
effective medication administra
 Difficulty of Provide patient understanding tion.
breathing The patient will be
able to expectorate about the proper use of
prescribed medications and
 Wheezes on retained secretions inhalers.
both lungs and maintain normal
breathing pattern.
 Productive
cough Chest physical therapy helps
mobilize bronchial secretions; it
Dependent: should be used only when
- Provide postural drainage, prescribed because it can
percussion, and vibration as cause harm if patient has
ordered. underlying conditions such as
cardiac disease or increased
intracranial pressure.

A variety of medications are

prepared to manage specific
problems. Most promote
clearance of airway secretions
and may reduce airway
resistance.
- Give medications as
prescribed, such as antibiotics,
mucolytic agents,
bronchodilators, expectorants,
noting effectiveness and side
effects.
 Consultants may be helpful in
ensuring that proper
treatments are met.
Collaborative:

Refer to the pulmonary clinical

nurse specialist, home health
nurse, or respiratory therapist
as indicated.