Patients Name: E. R. V. G.

Medical Diagnosis: Bronchopneumonia CUES NURSING PROBLEM Readiness for enhanced therapeutic regimen r/t wellness diagnosis SCIENTIFIC REASON The patient recovered from her illness. It resulted from following the pattern of regulating & integrating into daily living the treatment of illness that is satisfactory for meeting specific health goals.

Age: 1 Ward: Pediatric GOAL/ DESIRED OUTCOME Long-term goal: Upon discharge the patient will: -show normal vital signs (normal temp., RR & HR) -remain free of complications -show progress & enhance recovery
y y

Gender: Female Bed No. Crib - 2

Civil Status: Child

NURSING INTERVENTIONS Independent:

y Established interaction with the pt.s significant other Provided health teaching about the ff: -proper feeding

RATIONALE

EVALUATION

OBJECTIVE:
y y y y y no cough Afebrile Good cry Conscious No presence of mucous secretions

Builds trust & rapport

Patient showed compliance to nursing interventions

To give knowledge to the pt.s parents

Patient attained progress towards desired outcomes

y -discharge medications -follow up care Checked vital signs y

To improve pt.s health status & prevent sickness

To reassure that the patient is ready for discharge