NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: Impaired gas • Pneumonia is • After 4 hours • Assess • Manifestation • After 4
exchange r/t of nursing respiratory rate, of respiratory hours of
“Nahihirapan collection of an excess of
interventions, depth and ease. distress is nursing
huminga ang secretions fluid in the the patient will dependent on intervention
baby ko dahil sa affecting oxygen lungs achieve timely indicative of s, the
ubo” as exchange across resulting from resolution of the degree of patient will
verbalized by the alveolar an current lung achieve
mother. membrane. infection involvement timely
inflammatory
without and resolution of
Objective: process. The complications. underlying current
inflammation general infection
• Dyspnea is triggered by status. without
many • Monitor body • High fever complicatio
• Tachycardia infectious temperature. greatly ns.
increases
organisms
• V/S taken as metabolic
follows: and by demands and
inhalation of oxygen
T: 37.7 irritating consumption
P: 125 agents. and alters
R: 50 Infectious cellular
oxygenation.
pneumonias • Elevate head of • Promotes
are the bed and expectoration,
categorized change position clearing or
as community frequently. infection.
acquired • Limit visitors as • Reduces
(CAP) or indicated. likelihood of
exposure to
hospital other
acquired infectious
(nosocomial) pathogens.
depending on • Institute isolation • Isolation
where the precaution. technique
may be
patient was
desired to
exposed to prevent
infectious
agent. spread and
protect patient
from other
infectious
process.
• Suction as • Stimulates
indicated. cough or
mechanically
clears airway
in patient who
is unable to
cough
effectively.
• Assist with • Facilitates
nebulizer liquefaction
treatments. and removal
of secretions.
• Monitor • Signs of
effectiveness of improvement
antimicrobial in condition
therapy. should occur
within 24- 48
hrs.
Collaborative:
• Administer • These drugs
antimicrobials as are used to
prescribed. combat most
of the
microbial
pneumonias.