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ASSESSMENT NSG.

DIAGNOSIS PLANNING NSG RATIONALE EVALUATION


INTERVENTION

S: Impaired gas After 4 hours of • Assess • Manifestation of After 4 hours of rendering nursing
exchange r/t nursing respiratory respiratory interventions, the patient will achieve
“Nahihirapan huminga ang baby ko dahil collection of intervention,the rate, depth distress is timely resolution of current infection
sa ubo” as verbalized by the mother. secretions patient will achieve and ease. dependent on without complications.
affecting oxygen timely resolution of indicative of the
O: exchange across current infection degree of lung
alveolar without involvement and
• Dyspnea membrane. complications. underlying
• Tachycardia general status .
• V/s taken as follows : • Monitor body • High fever
temperature greatly increase
T: 37.7 metabolic
P: 125 demands and
R: 50 oxygen
consumption and
altery cellular
oxygenation.
• Elevate head • Promotes
of the bed expectoration ,
and change clearing or
position infection
frequently.
• Limit visitors • Reduces
as indicated likelihood of
exposure to other
infectious
pathogens
• Institute isolation • Isolation technique
precaution may be desired to
prevent spread and
protect patient from
ASSESSMENT NSG.DIAGNOSIS PLANNING NSG RATIONALE
other infectious EVALUATION
INTERVENTION agent
• Suction as indicated • Stimulates cough or
mechanically clears
airway in patient
who is unable to
cough effectively.
• Assist with • Facilitates
nebulizer treatment liquefaction and
removal of
secretions
• Administer anti • These drug are used
microbial as to combat most of
prescribed the microbial
pneumonias.
S: Ineffective airway After 8 hours of nursing • Assess respiratory • Usefull in After 8 hours of rendering
clearance related to intervention, the patient rate evaluating the nursing intervention, was
“Nahihirapan huminga excessive , thickened will demonstrate improved degrees or able to demonstrate
ang anak ko” as verbalized mucous secretions ventilation and adequate respiratory distress improved ventilation and
by the mother oxygen ; no signs of • Elevate head of the • Oxygen delivery adequate oxygen. And there
respiratory distress bed, assist patient, may be improved by is also no sign of
O: assume position to upright position and respiratory distress.
ease work of breathing axercises
• Presence of ronchi breathing. to decrease airway
• Ineffective cough Encourage deep collapse
• v/s taken as follows: slow or pursed lip
breathing as
T: 37.2 individually
P: 79 tolerated or
R: 24 indicated.
• Evaluate level of • During severe or
activity intolerance. acute respiratory
Provide calm and distress , patient
quiet environment may be totally
unable to perform
basic self care
activities because of
hypoxemia and
dyspnea.

ASSESSMENT NSG.DIAGNOSIS PLANNING NSG RATIONALE EVALUATION


INTERVENTION
S: Acute pain related to After 4 hours of nursing • Elevate head of the • Lowers diaphragm, After 4 hours of rendering
localized inflammation and intervention, the patient bed, change promoting chest nursing interventions, the
“Nahihirapan huminga ang persistent cough will display patent airway position frequently expansion nad patient was able to display
anak ko”, as verbalized by with breath sounds and expectoration of patent airway with breath
the mother. absence of dyspnea. secretions sounds clear and ansence
• Assist patient with • Deep breathing of dyspnea.
O: deep breathing facilitatesmaximun
exercises expansion of the
• Dyspnea lungs and smaller
• Fatigue airways
• v/s taken as follows: • Demonstrate • Coughing is a self
effective coughing cleaning position.
T: 27.1 while in upright Coughing in sn
P:80 position upright position,
R: 25 favors deeper, more
forceful cough
effort
• Force to increase • Fluids especially
fluid intake and warm liquids aid in
offer warm, rather mobilization and
than cold liquids expectoration of
secretions.