NURSING CARE PLAN

Client: N. D. Age: 39 Gender: MaleMedical Diagnosis: Community Acquired Pneumonia, Moderate Risk, PTB

PRIORITY #1: Ineffective Airway Clearance related to thick tenacious secretions and airway obstruction as evidenced by wheezes upon auscultation, shallow respiration, and tachypnea.

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Client verbalized, “Nahihirapan ako huminga dahil parang nakadikt na ata ang plema ko sa aking baga.”

>non-productive cough

>DOB

Objective

>Vital signsT:36.5PR:94RR:22BP:85/60

>inability to cough effectively

>wheezes noted upon auscultation

>with respiratory distress upon exertion

>positive chest retractions

Short-term goal

After 6 hours of nursing intervention:

>Client will be able to cough out effectively and clear airway secretions.

>Client’s SO will participate in the treatment regimen.

>Client will exhibit signs of comfortability and absence of irritation.

Long-term goal

>Client will maintain patency of airway and will have clear breath sounds.

Independent

1) Monitor VS every 2 hours

2) Encouraged patient to sleep with high-Fowler’s or semi-Fowler’s position.

3) Advise patient to turn patient every 2 hours and as needed.

4) Teach client to maintain adequate hydration by drinking at least 1-2 ml of fluid/day (if not contraindicated).

5) Taught and supervised effective coughing techniques.

6) Performed chest physio-therapy.

7) Monitor airway regularly for patency by auscultation.

1) To assess baseline data.

2) Promotes maximal lung expansion and decreases respiratory distress.

3) Repositioning aids in the drainage of pulmonary secretions.

4) To help in the thinning of secretions.

5) To conserve energy and effectively cough out secretions

6) Chest physiotheraphy facilitates secretion removal.

7) For the assessment of the required therapeutic regimen for the client.

After doing the necessary nursing interventions and teachings:

>Client’s SO responded to the health teachings performed regarding activity modification for the client to prevent fatigue.

>Client was able to cough out effectively

>Exhibited signs of decreased irritation

>Decreased difficulty of breathing

>Shows understanding of the goal towards activity modification.

8) Assisted in administering IV antibiotics and bronchodilators as ordered.

9) Instructed client/family to notify nurse if the client is experiencing shortness of breath or air hunger.

10) Instructed client/family regarding medications and symptoms of adverse effects to report to nurse or physician.

8) To improve ventilation and maximizes air exchange.

9) Indicates bronchial tubes are blocked with mucus, leading to hypoxia and hypoxemia.

10) Promotes client and client SO’s independence and adherence to the prescribed therapeutic regimen.

PRIORITY #2: Ineffective Breathing Pattern related to alteration of the normal oxygen saturation as evidenced by recurrence of DOB upon exertion

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATIONSubjective

>Client verbalized, “May mga times na hirap talaga akong huminga kahit wala naman akong ginawa.”

“Pagkatapos ko maglakad ng mahaba madalas nahihirapan na ko huminga.”

>Easy fatigability>Unproductive cough

Short-term goal

At the end of this shift, the client will:

>Be able to verbalize factors that causes his dyspnea.

>Verbalize lifestyle changes

Independent

1) Inspected the throat, describing the color, presence of exudates, or swelling.

2) Encouraged the client to increase the fluid intake.

3) Identified factors that causes his breathing impairment

1) To determine the cause of breathing problems This will provide a data that could be used to evaluate the proper intervention that the client needs.

2) To help in expectorating the mucus secretions.

3) This varies with each individual and situation.

After doing the necessary nursing interventions and teachings, the client:

>Verbalized awareness of factors that causes his breathing problems

>Verbalized understanding of the given information.

Objective>Vital signsT:36.5PR:94RR:22BP:85/60

>Shallow breathing through his mouth>Nasal flaring>Facial grimacing>Respiratory depth changes>Weakness in appearance>Wheezes noted upon auscultation

that he will do to avoid recurrence of dyspnea.

>Understand the health teachings

>Verbalize appropriate coping behaviors

4)Auscultate his chest

5) Reviewed the results of his laboratory testing like chest x-ray,02 saturation, and hematology.

6) Evaluate his cough and presence of secretions

7)Provided health teachings such as:-using of pursed-lip breathing technique

-activity modification

8) Encouraged the client to limit activities and avoid smokers, exposure to dust, perfumes, animals, etc.

9) Facilitated the use of nebulizer

4) To evaluate the character of breath sounds

5) To assess the cause of dyspnea and other respiratory problems

6) Secretions obstruct airways which causes breathing impairments.

>To assist the client in controlling dyspnea.

>to reduce fatigue

8)To limit fatigue that will cause dyspnea and SOB

9) To lessen respiratory distress

>Verbalized that he will adhere to the prescribed pharmacological regimen.

>Demonstrated use of relaxation skills.

>Responded to the health teaching

>Verbalized appropriate coping behaviors and lifestyle changes that he will do.

PRIORITY #3: Readiness for enhanced knowledge as evidenced by verbalization of interest in health teachings regarding diet/activity modification

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATIONSubjective:

>Verbalization of questions:“Gusto ko sana malaman kung ano ang mga pwede at diko pwedeng gawin pagkalabas dito?

>Expresses interest in learning

>Verbalized previous experiences regarding his disease.

>Easy fatigability

Objective:

>Patient for discharge

>Alert and coherent

>Ambulatory

>Vital signsT:37.7PR:94RR:26BP:140/90

Short term goal:

At the end of this shift, the client will:

>Verbalize that he will use given information in all applicable areas including environmental and personal.

>Verbalize understanding of the provided information.

>Use the information gained to meet her health care goals

1) Asked client of what’s his preferred methods of learning.

2) Encouraged client to explore on additional learning resources like internet and other medical books and references.

3)Teach client the following:-Stay calm as possible during asthma attack

-Pace activities.

-Avoid smoking, 2nd hand smoking

-Encourage increased fluid intake (uo to 3000ml a day) if there are no contraindications such as cardiac or renal disease.

1) To identify best approaches to facilitate learning progress.

2) To promote ongoing learning at his own pace.

-Anxiety during an asthma attack can further potentiate the exacerbation.-Fatigue can increase the work of breathing and decrease cough effectiveness.

-Avoids recurrence of symptoms

-Fluids are lost from mouth breathing and oxygen therapy.Maintaining hydration increases ciliary action to remove secretions and decreases viscosity of secretions.

After doing the necessary nursing health teachings, the client has:

>Responded to the learning plan and actions performed.

>Provided a positive feedback with the instructor.

>Verbalized understanding of the given info.

Fracture, Open, Segmented Tibia, Right; Fracture, Closed, M-D3, Fibula, Right

Priority 1: Acute pain related to soft tissue injury and wounds due to an external fixator in place as evidenced by client's verbalization of discomfort and irritability.Assessment Outcome Identification Intervention Rationale Evaluation

Subjective:Pain scale of 3/10

"Kumikirot siya kahit na hindi nagagalaw."

Pain is localized in the surgical site only.

Objective:Vital signs as are follows:T=36.9 PR=88 RR=20 BP= 115/70Client’s skin is cold.

Surgical incision is well coaptated. Non-erythematus. Absent dehiscence and evisceration, wound is not bleeding and has no foul odor.

Patient is moaning and restless.

Facial grimaces are observable during pain exacerbation.

After the necessary interventions the patient will:

Patient verbalizes pain relief or an acceptable reduction in pain.

Patient appears comfortable.

.

Assess for pain or discomfort.

Assess the patient's description of pain.

Administer analgesics as prescribed.

Provide health teachings on other non-pharmacologic interventions like deep breathing technique and diversional activities.

Assess effectiveness of pain-relieving interventions

Provides baseline for assessing changes in pain level and evaluating interventions.

Guides in the appropriate intervention applicable to his condition.

For pain relief. (Analgesics are more effective if administered early in the pain cycle; relief of pain)

Use of these strategies along with analgesia may produce more effective pain relief

Patient has a right to effective pain relief. It is not determined to be effective until the patient indicates that it is acceptable.

At the end of the 8hrs nursing care, the patient has:

Verbalized decrease in intensity of pain from 7/10 to 4/10.

Patient demonstrated relaxation techniques and diversional activities that enhance pain relief.

Priority 2: Impaired physical mobility related to external fixation device in place as evidenced by inability to move purposefully within physical environment.Assessment Outcome Identification Intervention Rationale Evaluation

Subjective:

"Sabi ng doctor bawal daw igalaw muna itong kanang hita ko."

"Medyo mahirap talaga kapag dika nakakagalaw galaw ng ayon sa gusto mo."

ObjectiveVital signs as are follows:T=36.9 PR=88 RR=20 BP= 115/70Client’s skin is cold.

Objective:Patient is confined to his bed, non-ambulatory

External fixation device attached to his right leg

Surgical incision is well coaptated; Non-erythematus; Absent dehiscence and evisceration; wound is not bleeding and has no foul odor.

After the necessary interventions the patient will:

Patient maintains maximum mobility within prescribed restrictions.

.

Assess for ROM of unaffected parts proximal and distal to the immobilization device

Determine the type of mobility supports the patient will require in anticipation of discharge.

Assess muscle strength in all extremities.

Administer analgesics as prescribed.

Encourage isometric, active, and resistive ROM exercises to all unaffected joints on a schedule consistent with the rehabilitation program and as tolerated.

Perform flexion and extension exercises to proximal and distal joints of the affected

Optimal ROM is critical for movement and necessary for rehabilitation.

Patient may require a cane, walker, or crutches to enhance ambulation.

The rehabilitation program will be geared toward maximizing strength in the unaffected extremities and maintaining as much strength as possible in the affected or immobilized extremity.

Exercise prevents muscle atrophy and maintains adequate muscle strength required for mobility.

These exercises serve to maintain mobility.

At the end of the 8hrs nursing care, the patient has:

Patient showed participation in doing the interventions and said that they were all beneficial for the enhancement of his mobilization.

Client said that he'll make sure to do those exercises whenever possible.

extremity, when indicated.

Apply splint to support foot in neutral position.

Place personal things like tissue paper, alcohol, etc within easy reach for the patient.

A splint prevents footdrop in patients immobilized in external fixation devices.

This will encourage the patient to have independence in doing things within the restrictions of his immobility.

Priority 3: Risk for constipation related to immobility and to the client's delaying the passing of his stools at night as evidenced by his verbalization of being uncomfortable defecating on his bed pan at daytime due to no privacy.Assessment Outcome Identification Intervention Rationale Evaluation

Subjective:Patient verbalized, "Pang-apat na araw ko na ngayon na hindi nakadumi."

"Nakakaramdam ako na madudumi na pero pag may bedpan na hindi naman matutuloy.

"Normally every day naman ako nagbabawas."

Objective:Hypoactive bowel sound 2-3 bowel sounds per 5 minutes

After the necessary interventions the patient will:

Patient passes soft, formed stool at a frequency perceived as normal by the patient.

Patient or caregiver verbalizes measures that will prevent recurrence of constipation.

Assess usual pattern of elimination; compare with present pattern, include size, frequency, color, and quality.

Evaluate laxative use , type, and frequency

Evaluate usual dietary habits, eating habits, eating schedule, and liquid intake.

"Normal" frequency of passing stool varies from twice daily to once every third or fourth day. It is important what is "normal" to each individual.

Chronic use of laxative causes rebound constipation. Over time the colon becomes atonic and distended.

Change in meal time, type of food, disruption of usual schedule, and anxiety can lead to

At the end of the 8hrs nursing care, the patient has:

Patient was able to know the factors that could cause being constipated.

Patient was able to determine that his immobility has contributed to the decreased motility of his GI tract

Abdomen does not appear to be distended; soft and non-tender upon palpation

.

Evaluate current medication usage that may contribute to constipation.

Assess the need for privacy for elimination.

constipation.

Drugs that can cause constipation include the following: narcotics, antacid with calcium or aluminum base, antidepressants, anticholinergics, antihypertensives, general anesthetics, hypnotics, and iron and calcium supplements.

Many individuals report that being away from home limits their ability to defecate

PRIORITY 3: Readiness for enhanced knowledge as evidenced by verbalization of interest in health teachings regarding diet/activity modification

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATIONSubjective:

>Verbalization of questions:“Gusto ko sana malaman kung ano ang mga pwede at diko pwedeng gawin pagkalabas dito?

>Expresses interest in learning

>Verbalized previous experiences regarding his disease.

>Easy fatigability

Objective:

>Patient for discharge

>Alert and coherent

>Ambulatory

>Vital signsT:37.7PR:94RR:26BP:140/90

Short term goal:

At the end of this shift, the client will:

>Verbalize that he will use given information in all applicable areas including environmental and personal.

>Verbalize understanding of the provided information.

>Use the information gained to meet her health care goals

1) Asked client of what’s his preferred methods of learning.

2) Encouraged client to explore on additional learning resources like internet and other medical books and references.

3)Teach client the following:-Stay calm as possible during asthma attack

-Pace activities.

-Avoid smoking, 2nd hand smoking

-Encourage increased fluid intake (uo to 3000ml a day) if there are no contraindications such as cardiac or renal disease.

1) To identify best approaches to facilitate learning progress.

2) To promote ongoing learning at his own pace.

-Anxiety during an asthma attack can further potentiate the exacerbation.-Fatigue can increase the work of breathing and decrease cough effectiveness.

-Avoids recurrence of symptoms

-Fluids are lost from mouth breathing and oxygen therapy.Maintaining hydration increases ciliary action to remove secretions and decreases viscosity of secretions.

After doing the necessary nursing health teachings, the client has:

>Responded to the learning plan and actions performed.

>Provided a positive feedback with the instructor.

>Verbalized understanding of the given info.

Prosthetic Joint Infection, Left Hip, Post-traumatic Osteomyelitis, Resolved Left Femur

Priority 1: Acute pain related to surgical incision for his prothethic implants and wounds for the external fixator as evidenced by client's verbalization of discomfort and irritability.Assessment Outcome Identification Intervention Rationale Evaluation

Subjective:Pain scale of 7/10

Pain is localized in the surgical site only.

Vital signs as are follows:T=36.2 PR=120 RR=23 BP= 120/70Client’s skin is cold.

Subjective:

After the necessary interventions the patient will:

Patient verbalizes pain relief or an acceptable reduction in pain.

Patient appears comfortable.

Assess for pain or discomfort.

Assess the patient's description of pain.

Administer analgesics as

Provides baseline for assessing changes in pain level and evaluating interventions.

Guides in the appropriate intervention applicable to his condition.

For pain relief.

At the end of the 8hrs nursing care, the patient has:

Verbalized decrease in intensity of pain from 7/10 to 4/10.

Patient demonstrated relaxation techniques and diversional activities

Surgical incision is well coaptated. Non-erythematus. Absent dehiscence and evisceration, wound is not bleeding and has no foul odor.

Patient is moaning and restless.

Facial grimaces are observable during pain exacerbation.

.

prescribed.

Provide health teachings on other non-pharmacologic interventions like deep breathing technique and diversional activities.

Assess effectiveness of pain-relieving interventions

(Analgesics are more effective if administered early in the pain cycle; relief of pain)

Use of these strategies along with analgesia may produce more effective pain relief

Patient has a right to effective pain relief. It is not determined to be effective until the patient indicates that it is acceptable.

that enhance pain relief.

Priority 2: Impaired physical mobility related to external fixation device as evidenced by inability to move purposefully within physical environment.Assessment Outcome Identification Intervention Rationale Evaluation

Subjective:Pain scale of 7/10

Pain is localized in the surgical site only.

Vital signs as are follows:T=36.2 PR=120 RR=23 BP= 120/70Client’s skin is cold.

Subjective:Patient is confined to his bed, non-ambulatory

External fixation device attached to his left leg

After the necessary interventions the patient will:

Patient maintains maximum mobility within prescribed restrictions.

.

Assess for ROM of unaffected parts proximal and distal to the immobilization device

Determine the type of mobility supports the patient will require in anticipation of discharge.

Assess muscle strength in all extremities.

Optimal ROM is critical for movement and necessary for rehabilitation.

Patient may require a cane, walker, or crutches to enhance ambulation.

The rehabilitation program will be geared toward maximizing strength in the unaffected extremities

At the end of the 8hrs nursing care, the patient has:

Patient showed participation in doing the interventions and said that they were all beneficial for the enhancement of his mobilization.

Client said that he'll make sure to do those exercises whenever possible.

Surgical incision is well coaptated. Non-erythematus. Absent dehiscence and evisceration, wound is not bleeding and has no foul odor.

Administer analgesics as prescribed.

Encourage isometric, active, and resistive ROM exercises to all unaffected joints on a schedule consistent with the rehabilitation program and as tolerated.

Perform flexion and extension exercises to proximal and distal joints of the affected extremity, when indicated.

Apply splint to support foot in neutral position.

Place personal things like tissue paper, alcohol, etc within easy reach for the patient.

and maintaining as much strength as possible in the affected or immobilized extremity.

Exercise prevents muscle atrophy and maintains adequate muscle strength required for mobility.

These exercises serve to maintain mobility.

A splint prevents footdrop in patients immobilized in external fixation devices.

This will encourage the patient to have independence in doing things within the restrictions of his immobility.

Priority 3: Constipation related to immobility as evidenced by frequent but nonproductive desire to defecate.Assessment Outcome Identification Intervention Rationale Evaluation

Subjective:Patient verbalized, "Pang-apat na araw ko na ngayon na hindi nakadumi."

"Nakakaramdam ako na madudumi na pero pag may bedpan na hindi naman matutuloy.

"Normally every day naman ako nagbabawas."

Objective:Hypoactive bowel sound 2-3 bowel sounds per 5 minutes

Abdomen does not appear

After the necessary interventions the patient will:

Patient passes soft, formed stool at a frequency perceived as normal by the patient.

Patient or caregiver verbalizes measures that will prevent recurrence of constipation.

.

Assess usual pattern of elimination; compare with present pattern, include size, frequency, color, and quality.

Evaluate laxative use , type, and frequency

Evaluate usual dietary habits, eating habits, eating schedule, and liquid intake.

"Normal" frequency of passing stool varies from twice daily to once every third or fourth day. It is important what is "normal" to each individual.

Chronic use of laxative causes rebound constipation. Over time the colon becomes atonic and distended.

Change in meal time, type of food, disruption of usual schedule, and anxiety can lead to constipation.

At the end of the 8hrs nursing care, the patient has:

Patient was able to know the factors that could cause being constipated.

Patient was able to determine that his immobility has contributed to the decreased motility of his GI tract

to be distended; soft and non-tender upon palpation Evaluate current

medication usage that may contribute to constipation.

Assess the need for privacy for elimination.

Drugs that can cause constipation include the following: narcotics, antacid with calcium or aluminum base, antidepressants, anticholinergics, antihypertensives, general anesthetics, hypnotics, and iron and calcium supplements.

Many individuals report that being away from home limits their ability to defecate

Priority 1: Hyperthermia related to disease process, humid environment as evidenced by elevated temperature of 38 °C, warm skin, tachypnea, and tachycardia.

Assessment Planning Intervention Rationale EvaluationSUBJECTIVE:“Parang mainit ang loob ng katawan ko”

OBJECTIVE:>Vital Signs taken as follows: T: 38 °C PR: 108 RR: 24 BP: 110/70> elevated temperature of 38°C and RR is 24>tachycardia

After performing the nursing interventions, client will:

> Maintain core temperature within normal range.

> Demonstrate behaviors to monitor temperature.

>Significant Others would demonstrate proper way of

>Monitor the client’s temperature.

>Note presence or absence of sweating as body attempts to increase heat loss by evaporation, conduction, and diffusion

>Promote surface cooling by means of undressing or removing extra clothing

>Note sudden changes in client’s body temperature

>Evaporation is decreased by environmental factors of high humidity and high ambient temperature.

>Heat lost by radiation and conduction

After performing the nursing interventions:

>Client’s caregiver demonstrated how to do tepid sponge bath especially when fever comes back.

>After 2 hours, client’s temperature dropped to 36 °C from 38 °C

>tachypnea> Skin is warm to touch> Exhibited signs of restlessness/weakness

doing tepid sponge bath >Promote a cool environment like the use of electric fan

>Teach client or caregiver on how to do a tepid sponge bath

>Discuss importance of adequate fluid intake

COLLABORATIVE:>Administer antipyretics: Drug: ParacetamolDrug Dosage:* 300 mg/IV if T ≥ 38.8°C * 500mg/tab if T ≥ 37.8 °C every 4 h

>Heat is lost by convection

>Heat loss by conduction and evaporation especially in the groin and axillae because these are areas of high blood flow

>Prevent dehydration

>Treat underlying cause

Priority 2: Acute pain related to disease process as evidenced by lymphadenopathy and swelling at the right submandibular area with a verbal report of pain (7/10), intermittent pain at the sternal area with a pain scale of (9/10), dysphagia

Assessment Planning Intervention Rationale EvaluationSUBJECTIVE:>“Sobrang sakit ng dibdib at dito sa gilid ng mukha ko.” (Client points at her right submandibular area)>Pain scale of 7/10 and 9/10

OBJECTIVE:>guarding position> weak appearance> presence of lymphadenopathy at the right submandibular area>intermittent pain on the sterna area

After performing the nursing interventions, client will:

>Verbalize relief of pain

>Cite the relaxation techniques taught

> Perform deep breathing exercises so that pain will be reduced.

>Assess pain, noting location, characteristics, intensity (0-10 scale).

> Encourage patientto verbalize concerns. Actively listen to theseconcerns and provide support by acceptance,remaining with patient and giving appropriate information.

> Provide comfort measure like back rub or deep

> Helps evaluate degree of discomfort and may reveal developing complications.

> Reduction ofanxiety or fearthat can promoterelaxation and comfort.

> Reduces muscletension,

After performing the nursing interventions, client:

>Verbalizes slight relief of pain but still it was present with a rate of 7/10

>Cited the relaxation techniques correctly

> Client also performed deep breathing exercises in reducing discomfort.

>dysphagia>dysphasia – due to lymphadenopathy / tonsillar abscess> Vital Signs taken as follows: T: 36°C PR: 98 RR: 22 BP: 110/70

breathing exercises.

>Encourage socialization with others, listen to the radio or read some magazines and newspapers if the client wanted to.

> Provide rest periods to facilitate comfort, sleep, and relaxation. The patient’s experiences of pain may become exaggerated as the result of fatigue.

COLLABORATIVE:>Administermedications asindicated:Drug: TramadolDrug dosage: 50 mgRoute: I.V.Frequency: q. 8 h

promotesrelaxation, andmay enhancecoping abilities.

>These are used to divert client’s attention on the pain

> Pain may result in fatigue, which may result in exaggerated pain and exhaustion. A quiet environment, a darkened room, and a disconnected phone are all measures geared toward facilitating rest.

> Relieves pain, enhances comfort and promotes rest.

Priority 3: Risk for infection related to immunosuppression and presence of IV catheter.

Assessment Planning Intervention Rationale Evaluation

OBJECTIVE:> Vital Signs taken as follows: T: 36°C PR: 98 RR: 22 BP: 110/70> Lab result: Low RBC,

After performing the nursing interventions, client will:

>Verbalize understanding of risk factors

> Develop no signs of

> Inspect skin describing wound characteristics and any changes being observed.

> Prevent infection through proper wound cleaning

> Monitor wound healing progress

> A contaminated wound is more likely to become infected.

After performing the nursing interventions, client:

>Verbalized understanding of risk factors

> Developed no visible

Low WBC > Presence of a IV catheter at the dorsum of the left hand.

inflammation, infiltration and infection on IV site > Discuss the importance

of early detection of skin changes

> Teach client and significant other about wound care and inspection of wound drainage

> Discuss patient’s diet with increased intake of Vitamins A, C, D, & E and protein once client is allowed

>Observe good oral hygiene.

>As much as possible, minimize puncturing of needle into client’s skin

>Always wear a mask

> Prevent further complications

> Prevent any complications

> Aids in wound healing by providing positive nitrogen balance. Protein is for rebuilding of cells and Vit. A & C are for re-epithelialization.

>Gargle with mouthwash to prevent bacteria from multiplying so as to prevent further infection.

>Since client is on immunosuppressant medication, lesser trauma to the skin is encouraged due to inhibition of immunocompetent T lymphocytes.

>Client on immunosuppressive medication and is admitted in a ward increasing the chance of harboring infection from other patients.

signs of inflammation, infiltration and infection on IV site until the end of the shift

PRIORITY #1: Acute Pain/Discomfort related to respiratory distress as evidenced by complaints of discomfortASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

>Client verbalized, "Hirap na

Short term goal:

At the end of this shift, the After doing the necessary nursing health teachings,

hirap na akong huminga at ang sikip-sikip ng dibdib ko. Tulungan mo ako."

>"Ang hirap at masakit sa dibdib habang hinahabol ko ang aking paghinga."

>Pain scale 4/10

Objective:

>Shallow breathing through his mouth>Nasal flaring>Facial grimacing>Respiratory depth changes>Weakness in appearance

>Vital signsT:36.3 PR:110RR:33BP:170/90

client will:

>Patient verbalizes relief or reduction in pain from 4/10 to 2/10.

>Patient appears relaxed and comfortable.

>Patient verbalizes the understanding of non-pharmacological interventions for pain relief.

1) Assess complaints of discomfort: pain or discomfort with breathing, shortness of breath, muscle pains, pain with coughing.

2) Monitor for non-verbal signs of discomfort like grimacing, irritability, tachycardia, increased BP.

3.) Elicit how the patient has effectively dealt with pain in the past.

4) Administer appropriate medication

5) Administer analgesic as prescribed and as needed.

6) Use additional measures, including positioning and relaxation techniques like deep breathing exercices, pursed lip breathing as indicated.7) Auscultate the lungs after the interventions.

1) Pain can result in shallow breathing and poor cough effort.

2) Specific manifestations guide interventions.

3) This provides opportunity to consider the patient's reactions to and expectations for pain relief.

4) Careful balancing of dosage is needed to prevent reduction in respirations seen with some analgesics.

5) Medications allow for pain relief and the ability to deep breath and cough. Analgesic prevent peak periods of pain6) These facilitates effective respiratory excursion

7) This helps to evaluate the effectiveness of the interventions done.

the client has:

>Clients appreciates the effectiveness of the interventions

>Verbalized awareness of factors that causes her breathing problems and able to use means to reduce the pain

>Able to demonstrate back the non-pharmacologic therapy for pain relief and understood the rationale of having to do them.

.

PRIORITY #2: Ineffective Breathing Pattern related to alteration of the normal oxygen saturation as evidenced by recurrence of DOB upon exertion

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

Subjective

>Client verbalized, “Paminsan-minsan nahihirapan ako huminga, minsan nawawala tapos bumabalik din kapag pagod ako.”

“Pagkatapos ko maglakad ng mahaba madalas nahihirapan na ko huminga.”

>Easy fatigability

Objective>Vital signsT:36.3PR:110RR:33 beats/minBP:170/90

>Shallow breathing through his mouth>Nasal flaring>Facial grimacing>Respiratory depth changes>Weakness in appearance

Short-term goal

At the end of this shift, the client will:

>Be able to verbalize factors that causes her dyspnea.

>Verbalize lifestyle changes that she will do to avoid recurrence of dyspnea.

>Understand the health teachings

>Verbalize appropriate coping behaviors

Independent

1) Inspected the throat, describing the color, presence of exudates, or swelling.

2) Encouraged the client to increase the fluid intake.

3) Identified factors that causes his breathing impairment

4)Auscultate his chest

5) Reviewed the results of his laboratory testing like chest x-ray,02 saturation, and hematology.

6) Evaluate his cough and presence of secretions

7)Provided health teachings such as:-using of pursed-lip breathing technique

-activity modification

8) Encouraged the client to limit activities and avoid smokers, exposure to dust, perfumes, animals, etc.

1) To determine the cause of breathing problems This will provide a data that could be used to evaluate the proper intervention that the client needs.

2) To help in expectorating the mucus secretions.

3) This varies with each individual and situation.

4) To evaluate the character of breath sounds

5) To assess the cause of dyspnea and other respiratory problems

6) Secretions obstruct airways which causes breathing impairments.

>To assist the client in controlling dyspnea.

>to reduce fatigue

8)To limit fatigue that will cause dyspnea and SOB

After doing the necessary nursing interventions and teachings, the client:

>Verbalized awareness of factors that causes his breathing problems

>Verbalized understanding of the given information.

>Verbalized that he will adhere to the prescribed pharmacological regimen.

>Demonstrated use of relaxation skills.

>Responded to the health teaching

>Verbalized appropriate coping behaviors and lifestyle changes that she will do.

9) Facilitated the use of nebulizer

9) To lessen respiratory distress

PRIORITY #3: Readiness for enhanced knowledge as evidenced by verbalization of interest in health teachings regarding diet/activity modification

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

>Verbalization of questions:“Ano ba ang mga dapat kong iwasan pag labas ko dito?

>Expresses interest in learning

>Verbalized previous experiences regarding his disease.

>Easy fatigability

Objective:

>Patient for discharge

>Alert and coherent

>Ambulatory

>Vital signsT:37.7PR:94RR:26BP:140/90

Short term goal:

At the end of this shift, the client will:

>Verbalize that he will use given information in all applicable areas including environmental and personal.

>Verbalize understanding of the provided information.

>Use the information gained to meet her health care goals

1) Asked client of what’s his preferred methods of learning.

2) Encouraged client to explore on additional learning resources like internet and other medical books and references.

3)Teach client the following:

-Avoid smoking, 2nd hand smoking and ingestion of alcohol

-Have adequate rest

-Avoid excessive activity

-Maintain proper cholesterol levels through dietary reduction of cholesterol intake and meds management and maintenance.

1) To identify best approaches to facilitate learning progress.

2) To promote ongoing learning at his own pace.

-Avoids recurrence of symptoms

-Prevents fatigue

-Prevents dyspnea

-To control CAD

After doing the necessary nursing health teachings, the client has:

>Responded to the learning plan and actions performed.

>Provided a positive feedback with the instructor.

>Verbalized understanding of the given info.