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.
College of Nursing Related Learning Experience Plan Course Title: NCM 109: Sample of Alternative Activities For Clinical Practice (RLE Equivalent 8 Hours)
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