ASSESSMENT DIAGNOSI INFERENCE PLANNING NTERVENTI RATIONALE EVALUATIO

S ON N
Subjective: Impaired Pneumonia After 4 hours Independent • Manifestatio After 4
“Nahihirapan gas is of nursing : n hours of
huminga ang exchange an excess of interventions, • Assess of respiratory nursing
baby ko dahil r/t fluid in the the patient respiratory distress is intervention
sa collection lungs will rate, dependent on s, the
ubo” as of resulting achieve depth and indicative of patient will
verbalized by secretions from timely ease. the degree of achieve
the affecting an resolution of • Monitor lung timely
mother. oxygen inflammatory current body involvement resolution
Objective: exchange process. infection temperature. and of
• Dyspnea across The without • Elevate underlying current
• Tachycardi alveolar inflammation complications head of general infection
a membrane. is triggered the bed and status. without
• V/S taken by change • High fever complicatio
as many position greatly ns.
follows: infectious frequently. increases
T: 37.7 organisms • Limit metabolic
P: 125 and by visitors as demands and
R: 50 inhalation of indicated. oxygen
irritating • Institute consumption
agents. isolation and alters
Infectious precaution. cellular
pneumonias oxygenation.
• Suction as
are • Promotes
indicated.
categorized expectoration,
as • Assist with
nebulizer clearing or
community infection.
acquired treatments.
• Monitor • Reduces
(CAP) or likelihood of
hospital effectiveness
of exposure to
acquired other
(nosocomial) antimicrobial
therapy. infectious
depending pathogens.
on • Isolation
where the technique
patient was may be
exposed to desired to
infectious prevent
agent spread and
protect patient
from other
infectious
process.
• Stimulates
cough or
mechanically