VIRAY, MESSIAH JEZREEL

NCP #3 for RHD

Cues Nursing Diagnosis Rationale Nursing Nursing interventions Rationale Expected

Subjective/Objecti Objectives Outcome
ve (Evaluation)

Subjective: Ineffective An ineffective Short-term Independent: May see use of accessory Goal met:
breathing pattern breathing pattern is a muscles for breathing, sternal
“Nahihirapan ako related to condition of Observe characteristics of retractions (infants and young
huminga” musculoskeletal inadequate ventilation breathing patterns children), nasal flaring, or
fatigue, low level of due to an impairment After 5 hours of nursing pursed lip breathing. Irregular Client’s response
Complaints of: consciousness as in the mechanism of intervention the patient Auscultate and percuss chest, patterns (e.g., prolonged to interventions,
manifested by inspiration and will achieve a normal, describing presence, absence, expiration, periods of apnea, teaching, and
● Breathlessn irregular breathing expiration. Prolonged effective respiratory and character of breath sounds obvious agonal breathing) actions
ess patterns and use of inadequate ventilation pattern as evidenced by may be pathological. performed.
● Palpitation accessory muscles may lead to the absence of cyanosis Elevate the head of the bed
compromised and other and/or have the client sit up in a Abnormal breath sounds are
Objective: signs/symptoms of
respiratory function chair, as appropriate, indicative of numerous The patient
performance, such as hypoxia, with arterial problems and must be
Fatigue, blood gasses (ABG’s) maintains an
Weakness, providing oxygen for Monitor pulse oximetry, as evaluated further effective
the tissues, and within the client’s normal indicated,
Bilateral pitting or acceptable range and breathing
pedal edema removing waste to promote physiological and pattern, as
products. decreased fatigue Teach the patient about pursed- psychological ease of evidenced by
BP:110/80 mmhg lip breathing, abdominal maximal inspiration relaxed breathing
breathing. at a normal rate
Pulse: 96 bpm Long-term to verify and depth and
Instructed client to include iron- maintenance/improvement in absence of
HGB :12.1gm/dL rich foods, such as green leafy O 2 saturation dyspnea
vegetables like Broccoli and Recognizing relationships
WBC:9,400 cells After 3-4 days of nursing spinach, red meat, and shellfish
intervention the patient
will demonstrate Incorporated citrus juice or foods
appropriate coping rich in Vitamin C to enhance iron
behavior and initiate absorption.
needed lifestyle
changes. Attainment or Helped the Client to understand
maintenance of the importance of adherence to
adequate nutrition. the medication.
Prioritize activities. Assist the
patient in prioritizing activities
and establishing a balance
between activity and rest that
would be acceptable to the
patient.
between specific activities The patient’s
and levels of fatigue can aid respiratory rate
the patient to recognize remains within
unnecessary energy outflow. established
The log may indicate times of limits.
day when the person feels the
least fatigued. This
information can help the
patient make choices about Reports less
setting his or her activities to fatigue.
take advantage of episodes of
high energy levels
Attains and
Fatigue may be a symptom of maintains
protein-calorie malnutrition, adequate
vitamin deficiencies, or iron nutrition.
deficiencies.

Changes in the patient’s sleep

Encourage the patient to pattern may be a contributing Maintains
maintain a 24-hour fatigue or factor in the development of adequate
activity log for at least 1 week fatigue. perfusion.

Evaluate the patient’s outlook for Absence of

fatigue relief, eagerness to complications.
participate in strategies toreduce
fatigue, and level of family and
social support.

Assess the patient’s sleep

patterns for quality, quantity, time
taken to fall asleep and feeling
upon awakening and observe
alteration in thought processes or
behaviors

Dependent:

Prescribed medications by
Doctors