NURSING

NURSING
ASSESSMENT PLANNING ANALYSIS INTERVENTIO RATIONALE EVALUATION
DIAGNOSIS
N
Subjective Independent:
Cues:
Ineffective Within 8 there is an ineffective breathing Established > Rapport is Goal met.
> Child states, breathing hours, pattern due to the infection and rapport important to gain Patient
“Mom, pattern related patient will use of accessory muscle patient’s exhibits a
my chest feels to exhibit cooperation normal and
heavy inflammatory normal and and reduce effective
when I effects effective anxiety. respiratory
breathe.” of pneumonia respiratory Obtained resting pattern as
pattern as vital > Baseline data is evidenced
evidenced by: signs important to help by:
Objective determine
Cues: (A state in which > respirations patient’s > respirations
an within current health within
> T= 39.2°C individual’s acceptable status N range
PR= 150 bpm inhalation range and evaluate
RR= 46 cpm and/or efficacy > absence of
exhalation > absence of of nursing signs and
> nasal flaring pattern does not signs and Placed patient in interventions symptoms of
with enable adequate symptoms of a rendered. cyanosis
shallow pulmonary cyanosis semi-Fowler’s to
breathing inflation or high- > An upright > normal ABG
emptying.) > normal Fowler’s position position and O2
> use of ABG and O2 promotes lung saturation level
accessory saturation expansion and
muscles levels mobilization of
secretions.
> crackles Repositioned
auscultated patient q
in ® upper lobe 2h > Frequent
repositioning
> productive prevents
cough pooling and stasis
with thick Assessed for
purulent patient’s secretions.
sputum vital signs and
observed for > Frequent
> diaphoresis & signs and assessment
pallor symptoms of provides
cyanosis information
> increased q2h about any
WBC improvement or
count deterioration in
patient’s
condition.