HARRIS COLLEGE OF NURSING AND HEALTH SCIENCES WRITTEN NURSING PROCESS

NAME William Murphy MEDICAL DIAGNOSIS: Pneumonia DATE 08/03/10

Nursing Diagnosis Goal as evidenced by Nursing Interventions**/Rationale Evaluation of Expected

Expected Outcomes* Outcomes***

Patient's breathing pattern

Ineffective Breathing will be restored by end of Assessment Intervention: By shift change the patient
Pattern Assess respiratory rate, rhythm, and depth b/c completely met her goal. The pt’s
shift breathing was unlabored, with a
(patient’s problem) changes are early warning signs of impending rate of 14, and was able to
(broad statement) respiratory difficulties. effectively use the spirometer.
R/T: Pneumonia
(medical diagnosis/condition)
AEB: as evidenced by Therapeutic Intervention:
AEB: By shift change the patient
unlabored breathing Encourage sustained deep breaths and use of
SOB partially met her goal by correctly
(patient’s S/S) (eupnea), normal breathing incentive spirometer, promoting deep using her spirometer, however, the
rate, and correct use of inspiration that increases oxygenation and patient’s breathing remained
spirometer by end of shift. prevents atelectasis labored and tachypnea.
Productive Cough
(patient’s S/S)

Abnormal Breath At shift change the patient’s goals

Education Intervention: were unmet. The patient’s
Sounds/Wheezing Teach patient appropriate breathing, coughing,
(patient’s S/S) breathing remained labored,
and splinting techniques that facilitate adequate tachypnea, and was unable to
DATA: clearance of secretion and prevent atelectasis. correctly use her spirometer thus
Subjective: reported SOB,
fatigue, reduced LOC, high
anxiety,

Objective:
Increased thick yellow
sputum; productive cough;
wheezing; suction in use;
fever; irregular breathing * ** ***
Assessment Interventions Completely Met
pattern Specific
Partially Met
Measurable Therapeutic Intervention
Attainable Education Intervention Unmet
Realistic
Timed