ASSESSMENT

NURSING OBJECTIV NURSING RATIONALE EXPECTE DIAGNOSIS INTERVENTIO D ES NS OUTCOM ES

S>

O> Patientmanifes ted the ff:

- with unproductive cough -with wheezes and crackles auscultated on left lower lungfield. - presence of clear watery discharge from her nose

> Patient may manifest the ff: - restlessness - irritability

Ineffective Short Term: >Establish rapport >To gain the Short Term: airway to patientand SO trust and clearancerelat cooperation ed to presence After 3-4 of secretions After 3-4 hours hours secondary ofnursing >To know and ofnursing topneumonia. interventions, >Assess patients determinepatien intervention s, ts needs the patients condition the patients respiration respiration will improve shall have and difficulty >To establish improved of breathing base line data and will be >Monitor and difficulty of relieved. record V/S breathing shall have >To identify been Long Term: >Auscultate lung areas of consolidation relieved. fields, noting and determine areas of possible decreased/absent bronchospasm After 3 4 airflow and or obstruction. days adventitious ofnursing Long Term: interventions, breath sounds the patientwil >To mobilize l maintain a After 3 4 patent airway >Assist patient to secretions days . change positionev ofnursing ery 30 minutes intervention s, the patientw >To facilitate ill have been >Elevate head of breathing able to bed and align head maintain a in the middle patent airwa y. >Provide health

teachings regarding effective coughing >To expel the mucous and deep breathing exercise.

>Encourage to increase fluidintake.

>Encourage steam inhalation >To liquefy secretions

>Administer meds >To moisten as ordered secretions and alleviate congestion

>To reduce bronchospasm and mobilize secretion