PROBLEM PRIORITIZATION Nursing Diagnosis/ Cues Ineffective breathing pattern related to decreased lung expansion Objective: • The respiratory

rate is 25 the patient seems to be in distress. • Dyspnea and orthopnea noted • Alteration in depth of breathing • Nasal flaring noted • Upon the test of lung excursion the patient the excursion wasn’t full • The patient was apprehensive Subjective: • The patient stated “medyo nahihirapan akong huminga, lalong lalo na pag nakahiga ako”. • He also added “nag-aalala na ko tingin hindi na to normal” Acute pain related to presence of tubes and drains Objective: • Guarding behavior, protective gestures, positioning to avoid pain • Facial mask of pain Subjective: • The patient mentioned “hindi ako makagalaw kasi masakit yung pinapasukan ng tubo ko” Measurement: • The patient rated the pain as 10 in the scale of 1-10 where 10 it the highest and 1 is the lowest. Impaired physical mobility related to discomfort at surgical site Objective: • Inability to move or change position when lying in bed • Needs assistance when sitting down • Demonstrates guarding behavior at The patient’s inability to move could slow down his recovery. It could also cause some problems like pneumonia and muscle atrophy. This has to be the second prioritized problem next to breathing pattern because pain can affect the treatment and cooperation of the patient it can also adhere his difficulty of breathing due to panic. It also limits his movements as stated by the client, thus slowing down his recovery. Justification This has been the prioritized problem because breathing pattern is important when it comes to ranking of problems. The sooner this problem gets resolved the lesser the complications like respiratory acidosis that could lead to a crisis.

surgical site Subjective: • The patient verbalized “hindi ako makagalaw kasi masakit yung pinapasukan ng tubo ko” • He also added “natatakot din ako matanggal yung tubo kaya ayoko gumalaw galaw.” Risk for infection related to invasive procedure Objective: • Chest tube attached to the patient. The fact that the patient has incision site would make him more vulnerable in developing infection directly to his systemic circulation and in his thorax and lungs.

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