ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
SUBJECTIVE DATA: Ineffective Within 6 to 8 • Elevate the head • Lower After rendering
“Nahihirapan akong airway clearance hours of of the bed diaphragm appropriate
huminga dahil sa ubo related to rendering promoting chest intervention, was
at plema” as verbalized increased appropriate expansion and able to
sputum intervention, will expectoration of expectorate
OBJECTIVE DATA: production as be able to secretion phlegm
Presence of evidenced by expectorate Goal met.
sputum noted productive cough phlegm • Assist change • To mobilize
(thick and with presence of position every 2 secretion
yellow with thick and yellow hours
streaks of sputum streaks
blood) of blood • Encourage liberal • To liquefy
Pain in right fluid intake secretion
chest that
intensifies with Scientific • Instruct to take • Warm fluids
inspiration Rationale: warm liquids help loosen
Productive -Presence of instead of cold ones secretions in the
cough bacteria in the lungs while cold
Difficulty of bronchioles that liquids trigger
breathing causes cough often
Auscultation productive
reveals bilateral cough. • Encourage and • This exercises
diminished demonstrate deep help breathing
vesicular breathing and huff and clear the
breath sounds coughing technique lungs
Bronchial
breath sounds,
rhonchi and • Encourage patient • To boost the
late inspiratory to increase intake immune system
crackles (are of nutritious food
heard) in the like fruits and
area of the right vegetables rich in
mid-anterior vitamin C
and right mid-
lateral lung • Facilitate quiet • To clear
fields environment and secretions and
Respiratory adequate rest maintain patent
rate taken: airway
RR: 24 cpm
• Perform • To humidify
suctioning as secretions
ordered
• Administer
oxygen therapy as
ordered
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
SUBJECTIVE DATA: Hyperthermia Within 1 hour of • Monitor the • For baseline After rendering
“Mainit at masama related to providing patient’s vital signs data appropriate
pakiramdam ko”- as infection process appropriate at least every 4 intervention,
verbalized as evidenced by nursing hours temperature was
temperature of intervention, the decreased from
OBJECTIVE DATA: 102.6 F temperature will • Provide tepid • Enhances heat 102.6 F to 98.9 F
Fever decrease from sponge bath loss by
(temperature Scientific 102.6 F to 98.9 F evaporation and
taken: Rationale: conduction.
102.6 F) The invasion of
Shaking the bacteria in the • Provide cool • Dissipates by
Chills body can regulate circulating air using heat convection.
Malaise the immune a fan.
Warm to response of the
touch body system • Place a cool cloth • These measures
which is or cooling patches help promote
increasing body on the client’s cooling and lower
temperature to forehead core temperature
eradicate the
foreign body.
• Position the • To provide
patient in a comfort
comfortable
position and elevate
the head of the
patient
• Facilitate bed rest • Reduces body
heat reduction.
• Assist patient in • Increases
changing into dry comfort.
clothing.
• Administer • To stop the
medications as infection and
prescribed control the fever.
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
SUBJECTIVE DATA: Acute pain Within 1-4 hour • Provide comfort • Patient After 1-4 hour of
“Masakit dibdib ko related to of providing measures: back involvement in providing
dahil hindi ako persistent cough appropriate rubs, position pain control appropriate
makahinga”- as as evidenced by nursing changes, quite measures nursing
verbalized pain in right intervention, music, massage. promotes intervention,
chest verbalize relief/ Encourage use of independence and verbalized relief/
OBJECTIVE DATA: control of pain relaxation and/or enhances sense of control of pain
Guarding Scientific breathing exercises. well-being
Behavior Rationale:
(holding his Chest pain is one
right chest of the most • Position the • To provide
using left arm) common patient in a comfort
Pain in right symptoms of comfortable
chest that pneumonia. position and elevate
intensifies Chest pain is the head of the
with caused by the patient
inspiration membranes in
Cough the lungs filling • Offer frequent • Mouth breathing
Continuously with fluid. This oral hygiene and oxygen
Apical heart creates pain that therapy can
rate taken: can feel like a irritate and dry
112 bpm heaviness or out mucous
Respiratory stabbing membranes,
rate taken: sensation and potentiating
24 cpm usually worsens general discomfort
with coughing
• Instruct and assist • Aids in control of
patient in chest chest discomfort
splinting while enhancing
techniques during the effectiveness of
coughing episodes cough effort
• Administer • These
antitussives as medications may
indicated. Do not be used to
suppress a suppress non-
productive cough; productive cough
moderate amounts or reduce excess
of analgesics are mucus, thereby
used to relieve enhancing
pleuritic pain. general comfort
• Administer • Medications
analgesics as allow for pain
prescribed. relief and the
Encourage patient ability to deep
to take analgesics breath and cough.
before discomfort Analgesics help
becomes severe. prevent peak
periods of pain
