NANDA Page 658

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
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
by:
Diminished
weakness
Diminished
Restlessness
Absence of
irritability
Patients name: A.A.
Cues/ Clues
Subjective:
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
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
are fully met as
evidenced by:
Decrease
irritability
Breathe without
difficulty
Have enough
rest at night
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
by:
Performed
treatment
regimen (deep
breathing
exercise)
Maintained
airway patency
Short-term goal:
After 12 hours of
by:
Decreased
irritability
Normal
breathing
Absence of
sleep
disturbance
Patients name: A.A.
Cues/ Clues
Nursing
Diagnosis
Inference
Goal and
Objectives
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
are fully met as
evidenced by:
State of feeling
well and well
rest
Diminish
yawning
Short-term goal:
After 12 hours of
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.
Independent:
Caffeine can
make you
hyperactive
To provide long
period of sleep
Long-term goal:
After 3 days of
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
by:
Decreased
restlessness
Decreased
weakness
Diminished
cough
Absence of
chest pain
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
are fully met as
evidenced by:
Exhibit
increase
interest and
assume
responsibility
for own
learning
Short-term goal:
After 12 hours of
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
by:
Exhibited
increase interest
and assume
responsibility for
own learning
Short-term goal:
After 12 hours of
by:
Participated in
learning process

NANDA Page 658

Uploaded by

Copyright:

Available Formats

NANDA Page 658

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

NANDA Page 658

Uploaded by

Copyright:

Available Formats

Patients name: A.A.

Age: 1 year and 2 months

Medical Diagnosis: Pediatric Community-Acquired Pneumonia

Patients name: A.A.

Age: 1 year and 2 months

Medical Diagnosis: Pediatric Community-Acquired Pneumonia

Patients name: A.A.

Age: 1 year and 2 months

Medical Diagnosis: Pediatric Community-Acquired Pneumonia

Patients name: A.A.

Age: 1 year and 2 months

Medical Diagnosis: Pediatric Community-Acquired Pneumonia

You might also like