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West Visayas State University

La Paz, Iloilo City


Name of Patient: RDC Attending Physician: Dr. G
Age: 60 yrs old Ward/Bed Number: MMSW/No .#3 Impression / Diagnosis: Obstructive jaundice secondary to hepatic
mass probably tuberculosis vs. malignancy alcoholic liver cirrhosis

Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Rationale Evaluation
December 6, 2017 After 5 hours of 1. Assess patient’s 1. To obtain baseline December 6, 2017
5 pm Ineffective Breathing Definition: nursing condition and data and to serve 10.00 pm
pattern related to Inspiration and/or intervention: monitor vital track important
alteration of normal expiration that does not signs and changes. Goal not met;
“Budlay mag
ginhawa kay ga O2:CO2 ratio provide adequate The patient will be record.  The patient did not
gutok akon tiyan” ventilation. able to establish a 2. Auscultate chest 2. To evaluate establish a normal
as verbalized normal, effective presence/character effective respiratory
and assess
pattern as evidence
respiratory pattern airway pattern. of breath sounds
by presence of
as evidenced and secretions respiratory distress;
Objective: Pathophysiology: absence of RR= 37 breaths/min;
 Wheezes heard
during expiration respiratory distress 3. Elevate head of 3. To promote O2 saturation= 96 %
upon Presence of fluid in the bed as physiological and
auscultation on peritoneal cavity will appropriate and psychological ease
all lung fields. result into a blockage of change position of maximal
 RR= 33 air that will enter the of the patient inspiration.
breaths/min diaphragm and thus every 2 hours.
 O2 saturation= producing insufficient air 4. Monitor pulse 4. To verify
96 % needed by the body. oximetry, as maintenance/impro
 Use of accessory
Doenges, et al. (2008). indicated vement in O2
muscles noted
Nurse’s Pocket Guide. saturation.
11th edition. Philadelphia:
F.A. Davis Company. p. 5. Observe nail 5. To identify
151. beds, skin and prersence of
color of tongue cyanosis
and mucus
Nurses Labs (2013) membranes
nchial-asthma-nursing- 6. Assist in ADL’s 6. For lesser oxygen
care-plans/ consumption
during activities
7. Demonstrate 7. Aid in increasing
and encourage use oxygen saturation
of deep breathing and will help in
exercises decreasing comfort

Student’s Name:
Clinical Instructor: