ASSESSMENT DIAGNOSIS Planning Intervention Evaluation

S> “Nahihirapan ako Ineffective Airway After 4 hours of Independent: >Goal partially met
makahinga.” as Clearance r/t nursing intervention, >VS monitored as evidenced by
verbalized by the accumulation of the patient will be >I&O monitored patient’s
patient secretions AEB able to maintain >O2 Inhalator verbalization: “Medyo
presence of thick airway patency. regulated @ 2 lpm okay na ang aking
O>seen patient on sputum >maintained on paghinga.”
bed in supine high CHON and cal
position
diet
>ambulatory
>febrile w/ temp =
>performed TSB
37.9°C >positioned client
>on high CHON on semi-fowler’s
and calorie diet position
>w/ O2 Inhalator via >CPT done after
NC nebulization
>(+) productive >Percussion done
cough q4°
>(+) thick sputum >instructed to do
>(+) wheezes DBE and coughing
>(+) fatigue excercises
>VS: >assisted in
BP: 120/80 changing position
mmHG q2°
RR: 22 cpm >encouraged to do
PR: 73 bpm ROM
DEPENDENT:
>Bronchodilator
given as prescribed
by the Dr.
>Antibiotics given as
prescribed by the Dr.
>Paracetamol givena
as prescribed by the
Dr.
ASSESSMENT DIAGNOSIS Planning Intervention Evaluation
S> “Wala akong Fluid and Electrolytes After 4 hours of Independent: >Goal partially met
ganang kumain.” as Imbalance r/t nursing intervention, >VS monitored as evidenced by
verbalized by the dehydration AEB loss the patient will be >I&O monitored patient’s
patient of apetite able to maintain fluid >IVF regulated @ 27- verbalization:
and electrolyte 28qtts/min “Nakakakain naman
O>seen patient on balance. >O2 Inhalator na ako.”
bed in supine regulated @ 2 lpm
position >maintained on
>ambulatory high CHON and cal
>febrile w/ temp =
diet
37.9°C >performed TSB
>on high CHON >instructed to
and calorie diet increase fluid
>w/ ongoing IVF intake
D5NSS x 1L @ 12° >assisted in skin
infusing well care
>w/ O2 Inhalator via >encouraged to do
NC ROM
>(+) weakness >health teaching
>(+) nausea about dietary
>(+) constipation regimen and special
>(+) fatigue need for calories, fat,
>(+) weight loss and vitamins.
>(+)pallor DEPENDENT:
>(+)dry skin >Paracetamol givena
>(+)clubbing as prescribed by the
>VS: Dr.
BP: 120/80
mmHG
RR: 22 cpm
PR: 73 bpm