Actual

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective : Hyperthermia Within my 8hrs shift Independent  To elicit Goal met as
related to infection patient will cooperation. evidenced by :
“ init akong  Established
secondary to
paminaw ma’am .”  Decrease rapport.  To monitor  Temperature of
pneumonia.
as patient temperature the risk of 36.2 degree
 Monitored vital
verbalized . from 38.2 severe increase
signs  Verbalized
centigrade to of temperature
( temperature understanding
less than 36.5 .
time to time ). . of the health
 Verbalize the teaching and
 Assisted patient  Dissipates
Objective : comfort and known the
to change into the heat
understanding purpose of the
 Temperature of about the
dry clean convection .
drug given.
38.2 degree clothing.
rendered health
centigrade. teaching.  Performed
 Promotes heat
 Skin warm to sponge bath.
loss trough
touch.
evaporation .
 Flush facial
skin .
 Promoted bed  It reduces body
 Irritability noted
rest . heat production.
 Dry mucous
 Provided cool  Increases
membrane .
environment . comfort.
 Teary eyes
 Encouraged  Prevents
noted.
and instructed dehydration.
SO to comply
 increase oral
fluid intake .
Dependent
 Monitor I and O
of the patient as
ordered by the
physician .
 Regulated IV to
its desired rate
( 120 cc/hr ).
 Administered  Prevents
anti pyretic drug dehydration.
by the NOD.
( paracetamol
500 mg, PRN )  Help for faster
 Administered relief of fever .
antibiotic as
ordered.

 Treats
underlying
cause.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Ineffective airway After my 8 hrs of Independent Goal met as
clearance related to shift patient will able evidenced by :
“ kung mag ubo ko  Established
sputum to ;
ma’am naay plema rapport .  Improved ability
accumulation .  To elicit
gamay.” as patient  Verbalized to expectorate.
 Monitored cooperation.
verbalized expectoration of
vital signs .  Normal
the sputum .  To monitor
( respiratory respiratory rate
unusualities.
 Patient will rate from time of 19 cpm
Objective
stabilize normal to time ) and
 Understand
respiratory lung sound .
health
cycle in range
A. Respiratory rate  Positioned teachings
of 16-20 cpm,
of 25 cpm. the patient to imparted.
as well as the
HBR .
B. Abnormal lung rhythm.  Compliance of
sound noted  Encourage  for an easier medication
 Demonstrate
( crackle sound patient to do respiration. noted.
health teaching
noted ). deep breathing
rendered .  Comfort was
exercise.
C. Dyspnea noted . manifested.
 Compliance of  This may help
 Encouraged
medication as to relax
patient to
airway.and for
 ordered. increase oral constant
fluid intake . oxygenation.
 Instructed  This may
patient refrain help for sputum
from eating expectoration
throat irritating and promotes
foods. Such hydration.
as :chocolates
 Foods that
(sweets) and
is high sugar
dry foods .
may irritate
throat walls.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective : Impaired gas After my 8hrs of Independent
exchange related to shift the patient will
“ medyo nag lisod  Established  To elicit
inflamed lung lobe expected to :
pa ko mag rapport . participation
secondary to
ginhawa .” as
infection.  Monitored  To look for any
patient verbalized.
 Manifest normal vital signs . unusualities.
respiratory rate ( respiratory
ranges 16-20 rate from time
cpm . to time ) and
Objective : lung sound .
 Verbalize
 Xray improvement on  Positioned
findings/result her intermittent the patient to
( haziness on dyspnea HBR .  This may help
the at left lower episodes. to breath easily.
 Encourage
lobe may relate
 The oxygen patient to do
to inflammatory
saturation will deep breathing
or infection
increase to exercise.  This promotes
process ). relaxation.
95-100
 Encouraged
 Respiratory rate
patient to
of 25 cpm.
increase oral
 Dyspnea noted fluid intake .
 Promote
 Crackle sounds  Position hydration.
noted at the left and assist the
lower lung . patient to her
comfortable
 Oxygen area, to rest on
saturation of 90
both left and
right fingers. .
 Provide
safety.
 Bed rest
instructed .

 Adequate rest
may help for
fast recovery.
Potential
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Risk for deficient Within my 8hrs shift  Established  To elicit
fluid volume related the patient will rapport . cooperation.
“ grabe akong
to diaphoresis .
paningot ma’am ,”  Verbalize  Monitored  Serves as a
verbalized by the improvement of vital signs . baseline data.
patient. the condition .
 Monitored I  Balance of input
 Manifest and O and output must
compliance of be recorded.
 Encouraged
the increase
patient to  To promote
Objective fluid intake .
increase OFI. hydration .
 Diaphoresis  There will be no
 Encouraged  This may help
signs of any
 Fever of 38.2 c dehydration.
patient to eat for hydration.
fruits that is
high in fluid
content such as
watermelon and
grapes.
 Encouraged
to refrain from
engaging foods
that may cause  To reduce the
dehydration risk of further
such as coffee dehydration.
and tea.
 IVF should
 be regulated .

 Improper
regulation also
affects fluid
deficit.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective Risk for activity Within my 8hrs shift  Established  To elicit Goal met as
intolerance related the patient will ; rapport. cooperation. evidenced by:
 Dyspnea
to decrease
A. Participate  Monitored vital  Serves as a A. Active
 SOB oxygenation.
willingly in desired signs. baseline data. participation on the
 Swollen lung activity such as health teaching
 Encouraged  Serves a
lobes . deep breathing together with SO.
patient to eat source of
exercise.
healthy foods . energy and B. Able to perform
B. Patient will be minerals. ADL”s without
 Provided
able to do ADL’S assistance.
adequate rest.  To
according to her
replenish
ability and capacity.  Encouraged
energy.
patient to
increase oral  To promote
fluid intake. hydration.
 Provides safety  To prevent
by raising the from falling.
side rails,