CUES AND EVIDENCES subjective: ³maglisod ko ug ginhawa as verbalized by the patient. Objective: ‡ Presence of rhonchi. ‡ Ineffective cough.

‡ V/S taken as follows:

NURSING DIAGNOSIS ineffective airway clearance related to excessive, thickened mucous secretions


NURSING INTERVENTION 1. Assess respiratory.rate,

RATIONALE 1.Useful in evaluating the degree or respiratory distress and chronicity of the disease process.

Patient display improved ventilation and adequate oxygenation of tissues and Arterial blood gases (ABGs) within normal range and free from symptoms of respiratory distress.

After 8 hours of nursing interventions the patient will: ‡ Demonstrate improved ventilation and adequate oxygen. ‡ Arterial blood gases (ABGs) within normal range. ‡ No signs of respiratory distress. Long term:

depth. Note use of accessory muscles, pursed lip breathing, Inability to speak.

2.Oxygen delivery 2. Elevate head of the bed, assist patient assume position to ease work of breathing. Encourage deep slow or pursed lip breathing as individually tolerated or indicated. 3. Routinely monitor skin and mucous membrane color. 4. Encourage expectoration of sputum; suction when indicated 5.evaluate level of activity tolerance. Provide calm and quiet environment. may be improved by upright position and breathing exercises to decrease airway collapse, dyspnea and work of breathing. 3.Cyanosis may be peripheral in nail beds or central in lips or earlobes. Duskiness and central cyanosis indicate advanced hypoxemia. 4.Thick, tenacious, copious secretions are major source if ineffective airways. Deep suctioning may be required when cough is ineffective for expectoration of secretions. 5.during severe or acute respiratory distress, patient may be totally unable to perform basic self care activities because of hypoxemia and dyspnea. 6.Multiple external stimuli and presence of dyspnea may prevent relaxation and inhibit sleep. 7.Tachycardia, dysrhythmias, and changes in blood pressure can reflect effect of systemic hypoxemia on cardiac function. 8.May correct or prevent worsening of hypoxia.

T: 37.2 P: 79 R: 24 BP: 110/80

After months of nursing interventions, the patient: ‡ Ventilation or oxygenation is adequate to meet self care needs

6.Evaluate sleep patterns, note report of difficulties and whether patient feels well rested. 7. Monitor vital signs and cardiac rhythm. Collaborative: 8.Administer supplemental oxygen as indicated by ABG results and patients tolerance.

from To sustain the pt.¶s motivation . info. Conscious/c oherent Body malaise noted Difficulty moving left arm noted Facial grimace noted Pallor noted Complains of fatigue Jefherrson jemilo NURSING DIAGNOSIS Activity intolerance r/t to generalized body weakness as manifested by: Body malaise noted Difficulty moving left arm noted Facial grimace noted Pallor noted Complains of fatigue OBJECTIVE After 10 hours of nursing interventions the pt.¶s current activity tolera nce Adjust activity and reduce intensity of task that may cause undesired physiological changes Increase exercise and activity levels gradu ally Teach methods to conserve energy such as sitting than standing while dressing Assist the pt. Objective: Received awake lying on bed with an ongoing IVF of PLRS 1 L at 340 cc level regulated at 10 gtts. infusing well at right akong pamati as vervalize by the pt. That provides evidence of progress RATIONALE Provide cooperative baseline To overexertion prevent Enhance activity tolerance Helps mini mize waste of energy Prevent injury the pt. will participate willingly in necessary activIty Will be able to move her left arm with ease Learn how to conserve energy Verbalize relief from fatigue NURSING INTERVENTION Evalua te the pt. while doing ADLs Give the pt.CUES AND EVIDENCES Subjective: bug.

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