ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Ineffective OBJECTIVE:  Assess and monitor  This is indicative of Within 30 mins. of
airway respirations and respiratory distress ad/ nursing intervention, the
“Nahihirapan clearance Within 30 breath sounds, noting or accumulation of patient was able to
akong huminga” related to mins. of rate and sounds secretions demonstrate a reduction
as verbalized by increased nursing  Evaluate clients  To determine ability to of congestion
the patient sputum intervention, cough and protect own airway
production as the patient swallowing ability RR- 20cpm
evidenced by will  Auscultate breath  To have a baseline data
tachypnea demonstrate sounds Goal Met
OBJECTIVE: and verbalize  Elevate the head of  This takes advantage of
 Ineffective reduction of the bed or change gravity decreasing
cough congestion position every 2 pressure o the
 Restlessness hours diaphragm to enhance
 Use of GOAL: ventilation
accessory  Encourage deep  To maximize patient’s
muscles when At the end of breathing and effort
breathing the nursing coughing exercise
v/s rotation, the
 Suction the airway  To clear the airway
 BP 120/70 patient will be
 T 36.6 able to initiate
appropriate  Encourage  This helps in the
 P 102 Chestphysiotherapy expulsion of sputum.
actions
 R 24 independently
to reduce DEPENDENT
bronchial  Administer a  To stop the airway
congestion. bronchodilator as constriction
prescribed by the
physician
 Do nebulization as  This also aids in clearing
ordered by the the airway.
physician

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Imbalanced OBJECTIVE:  Determine client’s  To determine factors that Within 5 hrs. of nursing
nutrition: less ability to chew, can affect ingestion and intervention, the patient
“Nanghihina ako” than body Within 5 hrs. swallow, and taste digestion of nutrients. regained body strength
as verbalized by requirements of nursing food. and loss of appetite has
the patient related to intervention,  Assess drug  To determine factors that been relieved.
inadequate the patient interactions, disease may affect appetite, food
intake of will regain effects, allergies. intake or absorption. Goal Met
 NAME CLASS INDICATION DOSAGE SIDE EFFECTS NURSING
RESPONSIBILITIES

Hydrocortisone Steroid Treatment for IV 50mg q6 Rash, hives, itching, Monitor patient’s
Hormone or COPD, 6am, 6pm difficulty breathing, tightness weight, BP,
Cortizan Glucocorticoid Pneumonia. 8/4/10 in the chest, swelling of the electrolytes and
mouth, face, lips, or tongue, glucose levels.
black, tarry stools, chest pain;
eye pain or increased Monitor input-output
pressure in the eye, fever, ratio, report
chills, or sore throat, joint or hypertension, edema.
bone pain, mood or mental
changes (eg, depression); Assess mental status:
muscle pain or weakness, mood, mental
seizures, severe or persistent changes.
nausea or vomiting, stomach
pain or bloating, swelling of Assess carefully for
feet or legs, unusual weight signs of infection
gain or loss, vision changes, specially fever and
vomiting material that looks WBC count.
like coffee grounds.
 NAME CLASS INDICATION DOSAGE SIDE EFFECTS NURSING
RESPONSIBILITIES

Piperacillin Spectrum beta- Treatment for IV 2.25mg q6 Headache, dizziness, nausea, Ask patient if he/she
lactam COPD, 6am, 12nn, 6pm, stomach upset, or loose has allergic reaction
Tazobactam antibiotic of the Pneumonia. 12md stools, vomiting, fever, chest on penicillin.
ureidopenicillin 8/4/10 pain, anxiety, unusual
class. bleeding or bruising. Obtain specimen for
culture and
sensitivity test before
giving first dose.

Drug contains 2.35

mEq sodium/g.
monitor sodium
intake.

Monitor hematologic
and coagulation
parameters.
 NAME CLASS INDICATION DOSAGE SIDE EFFECTS NURSING
RESPONSIBILITIES

Clarithromycin Macrolide Treatment for OD 500mg BID Diarrhea, nausea, extreme Assess patient’s
antibiotic. acute bacterial 8am, 6pm irritability, abdominal pain infection before
Claranta exacerbation 8/4/10 and vomiting, facial swelling. therapy.
of chronic Less common side-effects
bronchitis, include headaches, Obtain specimen for
pneumonia. dizziness/motion sickness, culture before
rashes, alteration in senses of starting the therapy.
smell and taste, including a
metallic taste that lasts the Assess bowel pattern,
entire time one takes it. Dry discontinue if severe
mouth, anxiety, diarrhea occur.
hallucinations.
Assess for possible
overgrowth or super
infection: perineal
itching, fever,
malaise, redness,
pain, swelling,
drainage, rash,
changes in cough,
sputum.