ASSESSM Obje INTERVENTION rationale implementation EVALUATION

ENT ctive of
care
After 4 Assess respiratory -Manifestation of respiratory distress is dependent on After 4
Subjective: hours rate, depth and ease. indicative of the degree of lung involvement and hours of
of underlying general status. nursing
nursing Monitor body -High fever greatly increases metabolic demands and intervention
Objective: intervent temperature. oxygen consumption and alters cellular oxygenation. s, the
• Dyspnea ions, patient will
• Tachycardi the Elevate head of -Promotes expectoration, clearing or infection. achieve
a patient the bed and timely
• V/S taken will change position resolution of
achieve frequently. current
as
follows: timely infection
resolutio Limit visitors as without
T: -Reduces likelihood of exposure to other infectious
P: n of indicated. complicatio
pathogens.
current ns.
R:
infection Institute isolation -Isolation technique may be desired to prevent
without precaution.
DIAGNOSI complic
spread and protect patient from other infectious process.
S ations. Suction as
Impaired gas -Stimulates cough or mechanically clears airway in patient
indicated.
exchange r/t who is unable to cough effectively.
collection of
secretions Assist with
-Facilitates liquefaction and removal of secretions.
affecting nebulizer
oxygen treatments.
exchange These drugs are used to combat most of the
across Administer
Microbial pneumonias.
alveolar antimicrobials as
membrane. prescribed.