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Name: Alyssa Rose G.

Macasieb Group: A3a Date: 03-19-2019


ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Impaired gas exchange •After 4hours of Independent: -Manifestation of After 4hours of
“Nahihirapan huminga related to collection of nursing -Assess respiratory rate, respiratory distress is nursing interventions,
ang baby ko dahil sa secretions affecting interventions, the depth and ease dependent on indicative of the patient will achieve
ubo” as verbalized by oxygen exchange across patient will achieve -Monitor body the degree of lung timely resolution of
the mother. alveolar membrane. timely resolution of temperature. involvement and current infection
current infection -Elevate head of the bed underlying general status. without
Objective: without and change position •High fever greatly complications.
•Dyspnea complications. frequently. increases metabolic
•Tachycardia -Limit visitors as demands and oxygen
•V/S taken as follows: indicated. consumption and alters
T: 37.7P: 125R: 50 -Institute isolation cellular oxygenation.
precaution. •Promotes expectoration,
-Suction as indicated. clearing or infection.
-Assist with nebulizer •Reduces likelihood of
treatments. exposure to other infectious
-Monitor effectiveness pathogens.
of antimicrobial •Isolation technique
therapy. may be desired to prevent
spread and protect patient
Collaborative: from other infectious
-Administer process.
antimicrobials as •Stimulates cough or
prescribed. mechanically clears airway
in patient who is unable to
cough effectively.
•Facilitates liquefaction
and removal of secretions.
•Signs of improvement in
condition should occur
within 24- 48hrs.
•These drugs are used to
combat most of the
microbial pneumonias.

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