Patients name: A.A.

Cues/ Clues
Subjective:
Objective:
(+) Chest pain
Weakness
Restlessness
Irritability
(+) productive
cough

Age: 1 year and 2 months

Nursing
Diagnosis
Acute pain
related to
cough
secondary to
pneumonia

Inference
Unpleasant
sensory and
emotional
experience
arising from
actual or
potential tissue
damage ;
sudden or slow
onset of any
intensity from
mild to severe
with an
anticipated or
predictable end
and a duration of
less than 6
months
(NANDA Page
658)

Medical Diagnosis: Pediatric Community-Acquired Pneumonia

Goal and
Objectives
Long-term goal:
After 3 days of
interventions, goals
are fully met as
evidenced by:
Diminish pain
Relax and
increase
activity
appropriately
Short-term goal:
After 12 hours of
interventions, goals
are fully met as
evidenced by:
Diminish
weakness
Diminish
Restlessness
Absence of
irritability

Nursing
Intervention
Independent:
Assess pain
level using
pain scale
Monitor vital
signs
Provide
convenient
measure
(music
therapy,
relaxation,
breathing
exercise)

Rationale

Evaluation

Independent:
To assess if the
pain is severe

Long-term goal:
After 3 days of
interventions, goals are
fully met as evidenced
by:

Observe non
verbal cues
and pain
expression

Use puppets
to
demonstrate
procedure for
child

Dependent:
Give Disudrin 2.5
ml BID for 2 weeks

To compared
with base line
data and check
if there is
abnormalities
The convenient
measure will
interfere with
pain and patient
is more focus in
relaxing
Observation
serves as an
indicator if the
client is unable
to verbalize
To enhance
understanding
and reduce pain
and anxiety

Dependent:
To improve
patency of
airway

Diminished pain
Relaxed and
increased
activity
appropriately

Short-term goal:
After 12 hours of
interventions, goals are
fully met as evidenced
by:
Diminished
weakness
Diminished
Restlessness
Absence of
irritability

Patients name: A.A.

Cues/ Clues
Subjective:

Age: 1 year and 2 months

Nursing
Diagnosis

Impaired gas
exchange
related to
alveolarObjective:
capillary
membrane
(+) non
productive cough changes
Difficulty in
secondary to
breathing
pneumonia
Irritability
Restlessness
Chest pain upon
coughing

Inference

Goal and
Objectives

Excess or deficit
in oxygenation
and/ or carbon
dioxide
elimination at the
alveolar-capillary
membrane

Long-term goal:
After 2 days of
interventions, goals
are fully met as
evidenced by:
Perform
treatment
regimen (deep
breathing
exercise)
Maintain airway
patency

(NANDA page
421)

Short-term goal:
After 12 hours of
interventions, goals
are fully met as
evidenced by:
Decrease
irritability
Breathe without
difficulty
Have enough
rest at night

Medical Diagnosis: Pediatric Community-Acquired Pneumonia

Nursing
Intervention

Rationale

Independent:
Independent:
Elevate the head
For easy access
and help change
of airway and
the position of the
proper breathing
client (semi fowler
or high fowlers
To prevent
position)
dehydration and
Insist the client to
moisten the air
increase oral intake
pathway
Auscultate for
Adventitious
any
breathe sounds
adventitious
can alter
breathe
respiratory
sounds
function
Monitor the
To check if
clients vital
theres a change
sign (heart
in the baseline
rate and
data
respiratory
rate)
Helps limit
Encourage
oxygen needs
adequate rest
and
and limits
consumption
activities
within client
tolerance
Dependent:
Dependent:
To inhibits
Give Cefuroxime
synthesis of
2.5 ml OD oral
bacterial cell
wall

Evaluation
Long-term goal:
After 3 days of
interventions, goals are
fully met as evidenced
by:
Performed
treatment
regimen (deep
breathing
exercise)
Maintained
airway patency
Short-term goal:
After 12 hours of
interventions, goals are
fully met as evidenced
by:
Decreased
irritability
Normal
breathing
Absence of
sleep
disturbance

Patients name: A.A.

Cues/ Clues

Age: 1 year and 2 months

Nursing
Diagnosis

Inference

Goal and
Objectives

Medical Diagnosis: Pediatric Community-Acquired Pneumonia

Nursing
Intervention

Rationale

Evaluation

Subjective:

Objective:
Cough
Chest pain
Restlessness
Afternoon nap
Weakness
Yawning

Disturbed
sleep pattern
related to
interruptions
secondary to
pneumonia

Time- limited
interruptions of
sleep amount
and quality due
to external
factors
(NANDA Page
878)

Long-term goal:
After 3 days of
interventions, goals
are fully met as
evidenced by:
State of feeling
well and well
rest
Diminish
yawning
Short-term goal:
After 12 hours of
interventions, goals
are fully met as
evidenced by:
Decrease
restlessness
Decrease
weakness
Diminish cough
Absence of
chest pain

Independent:
Discourage
intake of
foods and
fluids high in
caffeine

Offer client an
evening
snack that
includes milk
or cheese
Encourage
client to
urinate just
before
bedtime
Administer
medications
that can
interfere with
sleep early in
the morning

Dependent:
Give aldactone
early in the
morning

Patients name: A.A.

Age: 1 year and 2 months

Independent:
Caffeine can
make you
hyperactive

To provide long
period of sleep

Long-term goal:
After 3 days of
interventions, goals are
fully met as evidenced
by:

To avoid sleep
disturbance

To promote
longer period of
sleep and avoid
disturbances

Dependent:
To avoid
disturbance of
rest at night

Stated of feeling
well and rested
Absence of
yawning

Short-term goal:
After 12 hours of
interventions, goals are
fully met as evidenced
by:
Decreased
restlessness
Decreased
weakness
Diminished
cough
Absence of
chest pain

Medical Diagnosis: Pediatric Community-Acquired Pneumonia

Cues/ Clues
Subjective:

Objective:
Cough
Chest pain
Restlessness
Afternoon nap
Weakness
Yawning

Nursing
Diagnosis
Deficient
knowledge
related to
cognitive
limitation
secondary to
pneumonia

Inference
Absence or
deficiency of
cognitive
information
related to
specific topic
(lack of specific
information
necessary for
client to make
informed choices
regarding
condition,
treatment, and
lifestyle
changes)
(NANDA page
569)

Goal and
Objectives
Long-term goal:
After 2 days of
interventions, goals
are fully met as
evidenced by:
Exhibit
increase
interest and
assume
responsibility
for own
learning
Short-term goal:
After 12 hours of
interventions, goals
are fully met as
evidenced by:
Participate in
learning
process

Nursing
Intervention
Independent:
Determine
clients ability,
readiness,
and barriers
to learning

Be alert to
signs of
avoidance

Relate
information to
clients
personal
desires,
needs, values
and beliefs

Determine
clients
method of
accessing
information
(visual,
auditory and
etc.)

Rationale

Evaluation

Independent:
Individual may
not be
physically,
emotionally, or
mentally
capable at this
time
Client may need
to suffer
consequences
of lack of
knowledge
before he is
ready to accept
information
So that client
feels competent
and respected
To create
teaching plan
that will facilitate
learning or
recall

Long-term goal:
After 2 days of
interventions, goals are
fully met as evidenced
by:

Exhibited
increase interest
and assume
responsibility for
own learning

Short-term goal:
After 12 hours of
interventions, goals are
fully met as evidenced
by:
Participated in
learning process