Assessment “ nihindiko man langmasuklay and buhokko at malinisangsariliko” As verbalized by the client.

Objective: The client appears: • Inability to feed self independentl y • Inability to dress self independentl y • Inability to bathe and groom self independentl y • Inability to perform toileting tasks independentl

Nursing Diagnosis Self-care deficit related to impaired mobility status as manifested by activity intolerance.

Inferences

Planning After 1 hour of continuous nursing intervention the client will be able to perform self-care activity within level of own ability.

Nursing Intervention • Determine individual strength and skills of a client.

Rationale • Make appropriate technique that will facilitate teaching to develop plan of care appropriate to individual situation. To discover barriers to participation in regimen and to work on problem solutions.

evaluation After 8hours of continuous nursing intervention the client safely performs (to maximum ability) selfcare activities.

Plan a time for listening to the client concern

Allow sufficient time for dressing and undressing, since the task may be tiring,

• • To enhance sense of well-being . and difficult.• • y Inability to transfer from bed to wheelchair Inability to ambulate independentl y painful. Nurture individualized attributes such as humor. positive attitude. • Plan for person to learn and demonstrate one part of an activity before progressing further. and hope. faith.

Encourage deep breathing exercise Encourage adequate rest and limit Rationale • To identified causative and contributing factors.Assessment Subjective: “nakakramdam kongpaghiraps apaghinga ” as verbalized by the client. Nursing Intervention • Identified presence of factors that could contribute to impaired gas exchange such as environment and aging.72 bpm RR-30 bpm TempThe client appears: • Confusion • Somnolenc e • Restlessne ss Nursing diagnosis Impaired gas exchange related to pulmonary congestion as manifested by increased respiratory rate. evaluation • • • • • After 30minutes of nursing intervention the client demonstrate improved ventilation as evidenced by: • Reported improvem Positioning a ent of client breathing appropriately pattern such as and elevation of appear head helps rested. Objective: v/s: BP130/100mm hg PR. Client appears rested. Inference Planning After 30 minutes of nursing intervention the client will demonstrate improve ventilation as evidenced by: • Verbalized improveme nt of breathing pattern. Position client appropriately such as elevation of head. to promote maximal expansion of the lungs which enables the client to .

• • .• • Irritability Inability to move secretions • activities Provide psychological support by active listening to question concerns Administered oxygen as prescribed breath effectivelyan d improves the opening of the airway • Promotes optimal chest expansion Oxygen administratio n provides supplementa l oxygenation in the body.

Rationale evaluation Subjective: “ nahihirapanakongkumiloslalonakapagbumaba ngonako”as verbalized by the client. .72 bpm RR-30 bpm TempThe client appeared: • Verbal report of fatigue or weakness • Inability to begin or perform activity • Abnormal heart rate or blood pressure (BP) response to activity • Exertional discomfort or dyspnea • • Adjust activities or discontin ue activities that • After 8 hours of continuous nursing intervention the client was able to use identified technique to enhanced activity tolerance as evidenced by: • Client verbal izes and uses To energ preven yt conse overex To deter mine curren t status and needs associ ated with partici pation in desire d activiti es. Nursing intervention • Assess ability to stand and moveme nt and degree of assisted needed. Inferen ce Plannin g After 8 hours of continuo us nursing interventi on the client will use identified techniqu es to enhance activity tolerance . Objective: v/s: BP.130/100mmhg PR.Assessment Nursing diagnos is Activity intoleran ce related to immobilit y seconda ry to altered gas exchang e due to pulmona ry congesti on.

rvatio n techni ques. To conser ve energy and avoid extra consu mption of oxyge n. Assist client in learning and demonstr ating appropria te safety measure s. • Teach methods that facilitate conserva tion of energy such as having 3 minutes of rest during performin g activities.precipitat e the client’sco ndition. • • To preven t injurie s. Encourag • ertion. • • To enhan .

ce sense of wellbeing. suggest use of relaxatio n techniqu es such as visualizat ion.e client to maintain positive attitude. .

Goal met. Objective: Impaired gas exchange related to pulmonary congestion as manifested by increased respiratory rate. After 8 hours of nursing intervention the client demonstrate improvemed ventilation as evidence by: Reported decreased in RR Decreased crackles upon auscultation Client appear relaxed and • • • • • Observed restlessness and anxiety These are the common signs of hypoxia • • • Signs of cracles .Cues Nursing Diagnosis Inference Planning Nursing Intervention Rationale Evaluation Subjective: “ nakakaramada m ako ng paghirap sa paghinga” as verbalized by the client. After 8 hours of continous nursing intervention the client will demonstrate improvement of ventilation as evidenced by: • Decreased in rerpiratory rate Decreased crackles Client appear relaxed and comfortable • Identified prescence of factors that could contribute to inpaired gas exchange such as aging and environment Monitor vital signs. • To identified the causative and contributing factors • • • Monitoring vital signs reflect the client status.

Positioning the client appropriatel y helps to promote maximal expansion of the lungs which enables breath effectively and improves opening of the airway. • Position client appropriately such as elevation of the head at least 15 degree.• Auscultated the lungs for the sound of crackles • indicate accumulatio n of fluid in the lungs comfortable. .

• • Encourage deep breathing exercise • • Encourage adequate rest and limit activities Provide oxygen as ordered To breathe easier and to avoid respiratory distress To limit oxygen consumptio n Oxygen administrati on provides supplement al oxygenation in the body • • .

Cues Nursing diagnosis Inference Planning Nursing intervention Rartonale .

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