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    Cebu Institute of Technology - University College of Nursing

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    Sergi Lee Orate
    The patient presented with complaints of fatigue and difficulty breathing due to pneumonia. Upon assessment, the patient displayed decreased breath sounds, crackles on auscultation, elevated shoulders, and decreased fremitus. The nursing diagnosis was ineffective breathing pattern related to fatigue from pneumonia. The plan was for the patient to sustain a normal respiratory rate, tolerate daily activities, demonstrate proper breathing exercises, and decrease fatigue within 6 hours through nursing interventions like assessing airway patency, auscultating the lungs, and administering prescribed medications. The expected outcome was achieved as the patient's respiratory rate normalized, secretions decreased, and fatigue was alleviated.

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    Cebu Institute of Technology - University College of Nursing

    Uploaded by

    Sergi Lee Orate
    40 views2 pages
    The patient presented with complaints of fatigue and difficulty breathing due to pneumonia. Upon assessment, the patient displayed decreased breath sounds, crackles on auscultation, elevated shoulders, and decreased fremitus. The nursing diagnosis was ineffective breathing pattern related to fatigue from pneumonia. The plan was for the patient to sustain a normal respiratory rate, tolerate daily activities, demonstrate proper breathing exercises, and decrease fatigue within 6 hours through nursing interventions like assessing airway patency, auscultating the lungs, and administering prescribed medications. The expected outcome was achieved as the patient's respiratory rate normalized, secretions decreased, and fatigue was alleviated.

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    neruoncp1.docx

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    The patient presented with complaints of fatigue and difficulty breathing due to pneumonia. Upon assessment, the patient displayed decreased breath sounds, crackles on auscultation, elevated shoulders, and decreased fremitus. The nursing diagnosis was ineffective breathing pattern related to fatigue from pneumonia. The plan was for the patient to sustain a normal respiratory rate, tolerate daily activities, demonstrate proper breathing exercises, and decrease fatigue within 6 hours through nursing interventions like assessing airway patency, auscultating the lungs, and administering prescribed medications. The expected outcome was achieved as the patient's respiratory rate normalized, secretions decreased, and fatigue was alleviated.

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    40 views2 pages

    Cebu Institute of Technology - University College of Nursing

    Uploaded by

    Sergi Lee Orate
    The patient presented with complaints of fatigue and difficulty breathing due to pneumonia. Upon assessment, the patient displayed decreased breath sounds, crackles on auscultation, elevated shoulders, and decreased fremitus. The nursing diagnosis was ineffective breathing pattern related to fatigue from pneumonia. The plan was for the patient to sustain a normal respiratory rate, tolerate daily activities, demonstrate proper breathing exercises, and decrease fatigue within 6 hours through nursing interventions like assessing airway patency, auscultating the lungs, and administering prescribed medications. The expected outcome was achieved as the patient's respiratory rate normalized, secretions decreased, and fatigue was alleviated.

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    CEBU INSTITUTE OF TECHNOLOGY - UNIVERSITY

    COLLEGE OF NURSING

    NURSING CARE PLAN

    ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION


    (Subjective & (Dependent,
    Objective) Independent &
    Collaborative)
    Subjective: Ineffective breathing PTB occurs when M. After 6 hours of nursing Independent: >Maintaining the After 6 hours of nursing
    “naa mani sha pattern related to tuberculosis primarily interventions, the >assessed airway for airway is always the interventions, the
    pneumonia sir” as fatigue secondary to attacks the lungs. patient will be able to: patency first priority, especially patient was able to
    verbalized by the pneumonia A person with PTB may >Sustain respiratory in cases of trauma, display patency of
    patient. experience fatigue and rate within normal acute neurological airway as manifested
    Objective: loss of energy. It may range: RR= 12-20 cpm decompensation. by:
    >Decreased breath affect her ability to >Tolerate performance >auscultate lungs for >These may indicate >Patients’ RR is within
    sound expectorate secretions. of simple, day to day presence of normal or presence of mucus plug normal range: RR=20
    >Crackle sound noted Aside from that, activities. adventitious breath cpm
    >Elevated shoulders difficulty in breathing >Demonstrate proper sounds >secretions decreased
    >Decreased fremitus signifies that there may breathing exercises. -decreased breath >these may indicate >Patients’ fatigue was
    >Vital Signs: be an accumulation of >Decrease fatigue sound increase airway alleviated.
    R= 25 cpm secretions in the resistance
    BP= 110/80 mmHg bronchial cavity of the -coarse sounds >These may indicate
    lungs. Collaborative: fluid along larger
    Administer medications airways.
    Source: Medical as prescribed by the
    Surgical Nursing 13th physician.
    edition by Brunner and
    Siddhart

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