Professional Documents
Culture Documents
Assessment
Subjective:
May halak pa sya
at may plema pa rin
pag ubo nya as
verbalized by the
clients mother.
Objective:
-patient
demonstrates
persistent coughing
and dyspnea
-presence
abnormal
sounds
v/s
T=
P=
R=
of
lung
Nursing
Diagnosis
Ineffective
clearance
increased
producton.
Planning
Intervention
Independent
-Assess vital signs
Rationale
Evaluation
Short term goal:
GOAL
PARTIALLY
MET
-assess
respiratory -use of accessory muscle indicates an
movements and use of abnormal increase in work of
accessory muscles.
breathing.
-assess sputum color, -a sign of infection is discoloured
amount, and odor and sputum. An odor may be present.
report
Long term goal:
GOAL
-teach mother chest -for better excretion of sputum
PARTIALLY
physiotherapy
METMET
and
other
Nursing
Diagnosis
Planning
Intervention
Rationale
Independent
-monitor vital signs
- assess sputum
-to
monitor
treatmeant
effectiveness
Evaluation
Short term goal:
.
GOAL
PARTIALLY
of MET
Nursing
Diagnosis
Subjective:
Impaired physical
mobility related to
restrictive devices,
Objective:
-patient has O2
inhalation via nasal
canula
-with ongoing IVF
connected to left
arm
Planning
Short term goal:
- After 8 hours of
nursing intervention, the
client will be free of
complications
of
immobility as evidenced
by intact skin and
normal
bowel
movement.
Intervention
Rationale
Independent
- Instruct mother teach and
remind child not to remove
O2 inhalation
Evaluation
Short term goal:
GOAL MET