PNEUMONIA

ASSESSMENT NURSING ANALYSIS GOAL AND NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVE INTERVENTIO
S N

• Pneumonia • After 4 hours • Manifestation

is of nursing of respiratory
Impaired gas an excess of interventions, Independent: distress is • After 4
Subjective: exchange r/t fluid in the the patient will dependent on hours of
collection of lungs achieve timely indicative of nursing
“Nahihirapan
secretions resulting from resolution of the degree of intervention
huminga ang
affecting an current • Assess lung s, the
baby ko dahil sa
oxygen inflammatory infection respiratory rate, involvement patient will
ubo” as
exchange process. The without depth and ease. and achieve
verbalized by the
across inflammation complications. underlying timely
mother. alveolar is triggered general resolution of
• Monitor body
membrane. by temperature. status. current
Objectives: many • High fever infection
infectious greatly without
• Dyspnea • Elevate head of
organisms increases complications.
the bed and
and by metabolic
change position
inhalation of demands and
• Tachycardia frequently.
irritating oxygen
agents. consumption
Infectious • Limit visitors as and alters
pneumonias indicated. cellular
• Vital Signs are • Institute isolation oxygenation.
categorized precaution. • Promotes
Taken as Follows:
as community expectoration,
acquired • Suction as clearing or
(CAP) or indicated. infection.
RR:44Cpm hospital • Reduces
acquired • Assist with likelihood of
(nosocomial) nebulizer exposure to
depending on treatments.
PR: 135 where the other
patient was • Monitor infectious
TEMP: 36.8 exposed to effectiveness of pathogens.
infectious antimicrobial • Isolation
agent. therapy. technique
may be
desired to
prevent spread
and
protect patient
from other
infectious
process.
• Stimulates
cough or
mechanically
clears airway
in patient who
is unable to
cough
effectively.
Dependent:
• Facilitates
liquefaction
Administer
and removal
medication as of secretions.
ordered by the • Signs of
physician improvement
in condition
should occur
within 24- 48
hrs.
• These drugs
are used to
combat most
of the
microbial
pneumonias.