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1. Ineffective airway Clearance
2. Acute Pain
3. Activity Intolerance

PROBLEM #1: Ineffective airway Clearance

Assessment Diagnosis Scientific Objectives Nursing Rationale Expected

Explanation Interventions Outcome
S: Ineffective Ineffective airway STG: >Establish >to gain STG:
“Kahit airway clearance is the After 2 hours of rapport patient’s trust The patient shall
nakapahinga clearance inability to clear nursing have identified
lang ako related to secretions or interventions, >Take and >to obtain potential
hinihingal ako.” retained obstructions from the the patient will record vital signs baseline data complications
as verbalized by secretion as respiratory tract to identify potential and how to
the patient. evidenced maintain a clear complications >Assist client to initiate
by crackles airway. A dyspneic and how to position his head >position helps appropriate
O: on lungs person often appears initiate appropriately for maximize lung preventive or
The patient upon anxious and may appropriate age/ condition. expansion and corrective
manifested: auscultation experience preventive or Assist patient decrease actions
>Changes in shortness of breath, corrective with coughing respiratory
respiratory rate a feeling of being actions. and deep effort. Maximal
>Clear, watery unable to get enough breathing ventilation may
and retained air. Dyspnea have LTG: exercise. promote LTG:
secretions many causes, most After 5 days of >increase fluid movement of The patient shall
of which stem from nursing intake of patient secretion into have
cardiac and interventions, unless larger airways. demonstrated
respiratory disorders. the patient will contraindicated >high fluid absence or
It is a subjective demonstrate intake helps thin reduced
feeling as it cannot absence or secretions, congestion with
be directly observed reduced making them breath sounding
but is reported by the congestion with >keep easier to clear noiseless
patient. breath sounding environment expectorate. respirations and
clear noiseless allergen free improved
respirations and >Precipitators of oxygen.
improved allergic type of
oxygen respiratory
exchange. reactions can
trigger or
>administer onset of acute
bronchodilators episodes.
as physician
required, and >to widen and
use of relax air
nebulization as passages. To
necessary. reduce viscosity
of secretions.
Problem #2: ACUTE PAIN



S: Acute Pain related Unpleasant STG: >Assess pain >Chest pain, STG:
“Sobrang sakit ng to persistent sensory and After 4 - 6 hours characteristics: usually present to After 4 - 6 hours
pakiramdam ko coughing emotional of nursing sharp, constant, some degree with of nursing
tuwing ako ay as evidenced by experience interventions, the stabbing. pneumonia, may interventions, the
umuubo”, as reports of pleuritic arising from patient will be Investigate also herald the patient shall be
verbalized by the chest pain actual or able to verbalize changes in onset of able to verbalize
patient. potential tissue a decrease in character, location, complications of a decrease in
damage or pain scale from or intensity of pain. pneumonia, such pain scale from
described in 6/10 to 4/10 as pericarditis and 6/10 to 4/10
O: terms of such endocarditis.
The patient damage; sudden
manifested: or slow onset of
>Guarding any intensity >Monitor vital
behavior from mild to LTG: signs. >Changes in heart LTG:
>Discomfort severe with After 1 - 2 days rate or BP may After 1 - 2 days
anticipated or of nursing indicate that of nursing
predictable end interventions, the patient is interventions, the
and a duration of patient will be experiencing pain, patient shall be
<6 months. able to especially when able to
demonstrate a other reasons for demonstrate a
relaxed and relief changes in vital relaxed and
manner signs have been relief manner
ruled out

>Provide comfort > Non-analgesic

measures: back measures
rubs, position administered with
changes, quite a gentle touch can
music, massage. lessen discomfort
Encourage use of
relaxation and/or
>Mouth breathing
>ffer frequent oral and oxygen
hygiene. therapy can irritate
and dry out

>Aids in control of
>Instruct and chest discomfort
assist patient in while enhancing
chest splinting effectiveness of
techniques during cough effort.
PROBLEM #3: Activity Intolerance

Assessment Diagnosis Scientific Objectives Nursing Rationale Expected

Explanation Interventions Outcome
S:“Kahit Activity Activity Intolerance STG: >establish >to gain STG:
nakapahinga Intolerance is a state in which After 3 hours of rapport patient’s trust The patient
lang ako an individual has nursing shall have
hinihingal ako.” insufficient interventions, >Take and >to obtain identified
as verbalized physiologic or the patient will record vital baseline data negative
by the patient. psychological identify signs factors
energy to endure or negative affecting
O: complete required factors >Perform >Provides activity
The patient or desired activities affecting general cooperative tolerance and
manifested: which may be activity assessment. baseline data eliminated or
>Dyspnea and caused by low tolerance and Evaluate and reduced their
fatigue at rest oxygen supply in eliminate or clients actual information effects when
>The patient the blood vessels reduce their and perceived about needed possible.
receives and then manifests effects when limitations and education or
oxygen therapy as body weakness possible. severity of interventions
via nasal deficit in light of regarding
cannula at LTG: usual status. quality of life. LTG:
2-3LPM. After 4 days of The patient
nursing >reduce >to prevent shall have
interventions, intensity level overexertion reported
the patient will or discontinue measurable
report activities that increase in
measurable cause activity
increase in undesired tolerance.
activity physiological
tolerance. changes

>increase >to conserve

activities energy

>plan care to >To reduce

carefully fatigue
balance rest
periods with

>assist with >to protect

activities and patient from
provide or injury
monitor client’s
use of assistive

>plan for >promotes the

maximal idea of
activity within normalcy of
client’s ability progressive
abilities in this

>encourage >to promote

deep breathing maximal
exercises. expansion of