Patients name: F.R.

Cues/ Clues
Subjective:
As verbalized by the
patient:
Nahihirapan ako
huminga kapag
nakahiga
Masakit yung dibdib ko
kapag umuubo
Di ako makatulog dahil
sa ubo ko tuwing gabi
Objective:
(+) non
productive cough
Difficulty in
breathing
Irritability
Restlessness
Chest pain upon
coughing

Age: 55 years old

Nursing
Diagnosis

Inference

Impaired gas
exchange
related to
alveolar-capillary
membrane
changes
secondary to
pneumonia

Excess or deficit
in oxygenation
and/ or carbon
dioxide
elimination at the
alveolar-capillary
membrane
(NANDA page
421)

Goal and
Objectives

Medical Diagnosis: Community-Acquired Pneumonia

Nursing
Intervention

Rationale

Long-term goal:
Independent:
Independent:
After 3 days of
Elevate the head
For easy access
interventions, goals are
and help change the
of airway and
fully met as evidenced
position
of
the
client
proper breathing
by:
(semi fowler or high
Verbalize
fowlers position)
understanding
Insist the client to
To prevent
of causative
increase oral intake
dehydration and
factors and
and
check
the
IV
moisten the air
appropriate
respectively.
pathway
intervention

Auscultate
for

Adventitious
Perform
any
breathe sounds
treatment
adventitious
can alter
regimen (deep
breathe sounds
respiratory
breathing
function
Monitor the
exercise)
To check if
clients vital
Maintain airway
patency
sign (heart rate
theres a change
and respiratory
in the baseline
Short-term goal:
rate)
data
After 12 hours of
interventions, goals are Dependent:
Dependent:
fully met as evidenced
Give Ceftriaxone
To inhibits
by:
(Xtenda) 1mg IV
synthesis of
Decrease
Q12
bacterial cell wall
irritability
Collaborative:
Breathe without Collaborative:

Assist
the
client
on
Evaluation is
difficulty
consultation with a
necessary to
Have enough
radiologist for a
visualize the path
rest at night
chest x-ray report.
of airway

Evaluation
Long-term goal:
After 3 days of
interventions, goals are
fully met as evidenced
by:
Verbalized
understanding of
causative factors
and appropriate
intervention
Performed
treatment
regimen (deep
breathing
exercise)
Maintained
airway patency
Short-term goal:
After 12 hours of
interventions, goals are
fully met as evidenced
by:
Decreased
irritability
Normal breathing

Absence of sleep
disturbance

Patients name: F.R

Cues/ Clues
Subjective:
As verbalized by the
patient:
Malambot yung dumi ko
at kulay green
Naka-apat na dumi na
ako ngayong araw
Madalas ako mauhaw
Objective:

Watery stool
Muscle Weakness
Restlessness
Increase urine
output
(+) Abdominal pain
Hyperactive bowel
sounds
(+) Acute
gastroenteritis

Age: 55 years old

Nursing
Diagnosis
Risk for
electrolyte
imbalance
related to
diarrhea
secondary to
acute
gastroenteritis

Inference
At risk for
change in
serum
electrolyte
levels that
may
compromise
health
(NANDA
Page 341)

Goal and
Objectives

Medical Diagnosis: Community-Acquired Pneumonia

Nursing
Intervention

Rationale

Long-term goal:
Independent:
Independent:
After 3 days of
Assess for sudden
Decreased in
interventions, goals are
weight loss
weight results in
fully met as evidenced
deficit of fluid and
Administer fluid
by:
electrolytes
and electrolyte
Electrolytes and
To provide what
replacements if
fluids are balance
ordered
is loss in the
Normal bowel
body
sounds
Assist client to
Semi-form stools
select foods/fluids
Potassium is
high in potassium
essential for
Short-term goal:

Consult
physician
balancing
After 12 hours of
if
fluid
volume
electrolytes
interventions, goals are
fully met as evidenced
deficit and
by:
electrolyte
Decrease
imbalances persist
Deficit in fluid
restlessness
or worsen.
and electrolytes
Diminish muscle
can cause severe
Dependent:
weakness
dehydration that
Give Omeprazole 40mg
Normal urine
can lead to death
PO OD
output
Collaborative:
Assist the client on
consultation with a
medical technologist for Dependent:
It blocks the final
a fecalysis report.
step of acid
production
Collaborative:
To assess if there
is any pathogens,
parasites and

Evaluation
Long-term goal:
After 3 days of
interventions, goals are
fully met as evidenced
by:

Electrolytes and
fluids are
balanced
Normal bowel
sounds
Semi-formed
stools

Short-term goal:
After 12 hours of
interventions, goals are
fully met as evidenced
by:
Decreased
restlessness
Diminished
muscle
weakness
Normal urine
output

bacteria

Patients name: F.R.

Cues/ Clues

Age: 55 years old

Nursing
Diagnosis

Inference

Goal and
Objectives

Medical Diagnosis: Community-Acquired Pneumonia

Nursing
Intervention

Rationale

Evaluation

Subjective:
As verbalized by the
patient:
Di ako makatulog ng
maayos sa gabi kasi
sumasakit yung dibdib ko

Disturbed sleep
pattern related
to interruptions
secondary to
pnuemonia

Time- limited
interruptions of
sleep amount
and quality due to
external factors
(NANDA Page
878)

Di ako makatulog ng
maayos kasi ubo ako ng
ubo
Objective:
Cough
Chest pain
Restlessness
Afternoon nap
Weakness
Yawning

Patients name: F.R

Cues/ Clues

Nursing
Diagnosis

Long-term goal:
Independent:
Independent:
After 3 days of
Discourage
Caffeine can
interventions, goals are
intake of foods
make you
fully met as evidenced
and fluids high
hyperactive
by:
in
caffeine
State of feeling
To provide long
well and rested
Offer client an
period of sleep
Diminish
evening snack
yawning
that includes
milk or cheese
Short-term goal:
Encourage
To avoid sleep
After 12 hours of
client to urinate
interventions, goals are
disturbance
fully met as evidenced
just before
by:
bedtime
Decrease
To promote
Administer
restlessness
longer period of
medications
Decrease
sleep and avoid
that
can
weakness
disturbances
interfere with
Diminish cough
sleep early in
Absence of
the morning
chest pain
Dependent:
Dependent:
Give aldactone early
To avoid
in the morning
disturbance of
Collaborative:
rest at night
Coordinate with
Collaborative:
other health
To provide a
professional and
quiet
provide a quiet
environment and
environment
promote sleep
Age: 55 years old

Inference

Goal and
Objectives

Long-term goal:
After 3 days of
interventions, goals are
fully met as evidenced
by:

Stated of feeling
well and rested
Absence of
yawning

Short-term goal:
After 12 hours of
interventions, goals are
fully met as evidenced
by:
Decreased
restlessness
Decreased
weakness
Diminished
cough
Absence of chest
pain

Medical Diagnosis: Community-Acquired Pneumonia

Nursing
Intervention

Rationale

Evaluation

Subjective:
As verbalized by the
client:
Masakit yung dibdib ko
kapag umuubo ako
Objective:
(+) Chest pain
Weakness
Restlessness
Irritability
(+) Non productive
cough

Acute pain
related to
cough
secondary to
pneumonia

Unpleasant
sensory and
emotional
experience
arising from
actual or potential
tissue damage ;
sudden or slow
onset of any
intensity from
mild to severe
with an
anticipated or
predictable end
and a duration of
less than 6
months
(NANDA Page
658)

Long-term goal:
Independent:
After 3 days of
Assess pain
interventions, goals are
level using pain
fully met as evidenced
scale
by:

Monitor vital
Diminish pain
signs
Relax and
Provide
increase activity
convenient
appropriately
measure
(music therapy,
Short-term goal:
relaxation,
After 12 hours of
interventions, goals are
breathing
fully met as evidenced
exercise)
by:
Diminish
Dependent:
weakness
Give Salbutamol
Diminish
1neb Q12 neb
Restlessness
Absence of
Collaborative:
irritability
Coordinate with
other health
professional and
provide a quiet
environment

Patients name: F.R

Age: 55 years old

Independent:
To assess if the
pain is severe

To compared with
base line data
and check if
there is
abnormalities
The convenient
measure will
interfere with
pain and patient
is more focus in
relaxing

Dependent:
For patency of
airway
Collaborative:
To provide
relaxation and
peaceful
environment

Medical Diagnosis: Community-Acquired Pneumonia

Long-term goal:
After 3 days of
interventions, goals are
fully met as evidenced
by:

Diminished pain
Relaxed and
increased activity
appropriately

Short-term goal:
After 12 hours of
interventions, goals are
fully met as evidenced
by:
Diminished
weakness
Diminished
Restlessness
Absence of
irritability

Cues/ Clues
Subjective:

Nursing
Diagnosis

Ineffective
airway
As verbalized by the
clearance
client:
related to
exudate in the
Nahihirapan ako huminga alveoli
kapag umuubo ako
secondary to
pneumonia
Nahihirapan ako huminga
kapag nakahiga ako
Objective:

(+) Non productive

cough
Restlessness
Chest pain
Difficulty in
breathing

Inference
Inability to clear
secretion or
obstructions from
the respiratory
tract to maintain
a clear airway
(NANDA Page
85)

Goal and
Objectives

Nursing
Intervention

Long-term goal:
Independent:
After 3 days of
Auscultate for
interventions, goals are
any breath
fully met as evidenced
sounds
by:
Maintain
Monitor
patency of
respiratory
airway
patterns,
Diminish
including rate,
obstruction in
depth, and
the alveoli
effort.
Perform deep
Monitor pulse
breathing
oxygen
exercise
saturation level
Elevate the
Short-term goal:
After 12 hours of
head of the
interventions, goals are
bed
fully met as evidenced
by:
Encourage
Breath
increase fluid
comfortably
intake
Diminish chest
Dependent:
pain
Salbutamol 1neb
Provide airway
Q12 neb
clearance

Rationale
Independent:
It indicates
airway
obstruction

The repiratory
will increase if
there is an
obstruction

Evaluation
Long-term goal:
After 3 days of
interventions, goals are
fully met as evidenced
by:

Decrease O2
saturation level
indicate
hypoxemia
To promote lung
expansion
To hydrate and
moisten the
mucosa

Dependent:
To moisten the
mucosa
Collaborative:

Assist the client on

Collaborative:
consultation with a
To assess if there
medical technologist
is any presence
for a chest x-ray and
of bacterial
sputum test
infection

Maintained
patency of airway
Diminished
obstruction in the
alveoli
Performed deep
breathing
exercise

Short-term goal:
After 12 hours of
interventions, goals are
fully met as evidenced
by:
Breathed
comfortably
Diminished chest
pain
Provided airway
clearance