Subjective: ³Hindi ako makatulog dahilsaubo ko´ as verbalized by the patient. Objective: · Fatigue. · Dyspnea. · V/S taken as follows: T: 37.

7 P: 90 R: 22 BP: 110/80

Actvity intolerance related to exhaustion associated with interruption in usual sleep pattern because of discomfort, excessive coughing and dyspnea.

Coughing is the body's way of removing foreign material or mucous from the lungs and throat.

After 4 hours of nursing interventions , the patient will demonstrate a measurable increase in tolerance in activity with absence of dyspnea and excessive fatigue.

Independent: · Evaluate patient¶s response to activity. · Provide a quiet environment and limit visitors during acute phase. · Elevate head and encourage frequent position changes, deep breathing and effective coughing. · Encourage adequate rest balanced with moderate activity. Promote adequate nutritional intake. · Force fluids to at least 3000 ml per day and offer warm, rather than cold fluids. Collaborative: · Administer medications as prescribe: mucolytics orexpectorants.

Establishes patient¶s capabilities or needs and facilitates choice of interventions · Reduces stress and excess stimulation, promoting rest. · These measures promotes maximal inspiration, enhance expectoratio n of secretions to improve ventilation. · Facilitates healing process and enhances natural resistance · Fluids Especially warm liquids aid in mobilization and expectorationof secretions. · Aids in reduction of bronchospas m and mobilization of secretions.

Objective: -Dark circles under eyes -Restlessness -Irritability -Dozing -Yawning -Difficulty in arousal

Disturbed sleeping pattern r/t interruptions for therapeutics, monitoring, other generated awakening, and excessive stimulation (noise and lighting)

After 2 shifts, the patient will achieve optimal amount of sleep as evidenced by rested appearance, verbalization of feeling rested, and improvement in sleep pattern.

Assessed sleep pattern disturbances that are associated with specific underlying illnesses. Observed and obtained feedback from clients regarding usual bedtime, routines, # of hours of sleep, and environmental needs. Did as much care as possible without waking the client, and did as much care as possible while the patient is still awake. Explained necessity of disturbances for monitoring VS and care when hospitalized. Encouraged wearing eye cover, drinking warm milk, and sleeping at the same time

High percentage of sleep disturbances are affected by illnesses. - To determine usual sleep pattern and provide appropriate intervention. - To avoid disturbances during sleep, and to maximize sleeping process. - So that patient will have an understanding of the importance of care being done to him. Minimizes complaints. - To enhance ability to fall asleep.

Subjective: ³Mainitang pakiramdamko´ as verbalized by the patient. Objective: · Flushed skin, warm to touch. · Restlessness

Hyperthermia related to dehydration.

Infectious agents (Pyrogens) stimulate Monocytes release Pyrogenic cytokines stimulate Anterior hypothalamus results in Elevated thermoregulatory set point leads to Increased Heat conservation (Vasoconstriction/behaviour changes) Increased Heat production (involuntary muscular contractions) result in FEVER

Independent: · Monitor heart rate and rhythm. · Record all sources of fluid loss such as urine, vomiting and diarrhea. · Promote surface cooling by means of tepid sponge bath. · Wrap extremities with cotton blankets. · Provide supplemental oxygen. Administer replacement fluids and electrolytes. · Maintain bed rest. · Provide high calorie diet, tube feedings, or parenteral nutrition. · Administer antipyretics orally or rectally as prescribed by the physician.

Dysrhythmias and ECG changes are common due to electrolyte imbalance and dehydration and direct effect of hyperthermia on blood and cardiactissues. · To monitor or potentiates fluid and electrolyte loses. · To decrease temperature by means through evaporation and conduction. · To minimize shivering. · To offset increased oxygen demands and consumption circulating volume and tissue perfusion. · To reduce metabolic demands and oxygen consumption · To increased metabolic demands. · To facilitate fast recovery.