Assessment

SUBJECTIVE: The patient may report: Chest pain, heaviness, or pressure that may radiate to the shoulders, arms, neck, jaw, or upper abdomen.

Diagnosis
Gas exchange, impaired related to altered delivery of oxygen

Inference
an inflammation of the lung tissue affecting one or both sides of the chest that often occurs as a result of an infection. Infection can be caused by a lot of different microorganisms viruses (eg respiratory syncytial virus), bacteria, fungi (eg histoplasmosis) and parasites. In addition to infection, pneumonia can also be caused by corrosive chemicals breathed into the lungs or toxic smoke inhalation from a fire.

Goal
After 8 hours of nursing intervention the patient will: Remain free from pain Maintain stable vital signs. Maintain relaxed body posture.

Intervention
> Perform assessments every 4 hours of respiratory rate, temperature, and signs of airway effectiveness. > Give Oxygen

Rationale
>Evaluation and reassessment of the actions that will be / have been granted.

Evaluation
After 8 hours of nursing intervention the patient was free from pain, maintains stable vital signs, and relaxed body posture.

> Increased lung tissue oxygen supply > Eradication of the bacteria as a factor of disturbance cause

OBJECTIVE: Tachycardia Elevated blood pressure Jugular vein distention Cool, clammy skin

> Give antibiotics and antipyretics, assess the effectiveness and side effects (rash, diarrhea) > Perform a gradual suction > Record the results of the pulse oximeter when installed, every 2 - 4 hours

> Helping airway clearance. >Periodically Evaluate the success of therapy / health team action.

Assessment
SUBJECTIVE: Hindi namin siya makausap at nahimatay siya as verbalized by the daughter OBJECTIVE: Request for information. Agitated behavior Inaccurate follow through of instructions. V/S taken as follows: T: 37.2 P: 118 R: 18 BP: 240/120

Diagnosis
Risk for Prone behavior related to lack of knowledge about the disease.

Inference
High blood pressure (HBP) or hypertension means high pressure (tension) in the arteries. Arteries are vessels that carry blood from the pumping heart to all the tissues and organs of the body. High blood pressure does not mean excessive emotional tension, although emotional tension and stress can temporarily increase blood pressure.

Goal
After 8 hours of nursing interventions, the patient will verbalize understanding of the disease process and treatment regimen.

Intervention
Define and state the limits of desired BP. Explain hypertension and its effect on the heart, blood vessels, kidney, and brain.

Rationale
Provides basis for understanding elevations of BP, and clarifies misconceptions and also understanding that high BP can exist without symptom or even when feeling well. These risk factors have been shown to contribute to hypertension.

Evaluation
After 8 hours of nursing interventions, the patient was able to verbalize understanding of the disease process and treatment regimen.

Assist the patient in identifying modifiable risk factors like diet high in sodium, saturated fats and cholesterol. Reinforce the importance of adhering to treatment regimen and keeping follow up appointments. Suggest frequent position changes, leg exercises when lying down.

Lack of cooperation is common reason for failure of antihypertensive therapy. Decreases peripheral venous pooling that may be potentiated by vasodilators and prolonged sitting or standing.