Rationale/ Goals/Desired Nursing

Assessment Cues Nursing Diagnosis Rationale Evaluation

Pathophysiologic Basis  Outcome Intervention
Subjective Cues: Acute Pain r/t the Predisposing Precipitating After 8hrs of nursing INDEPENDENT: After 8 hours of
The patient persistent Factors: Factors intervention, client Monitor the To identify nursing intervention,
-68 years old -Smoker for
verbalized, “Ga coughing aeb will be able to: patient’s vital signs changes in the client was able to:
-Male 10 years
sakit akon tiyan Reports of -History of hell heart rate or blood
kada mag ubo-ubo discomfort: hypertension -Onset of Verbalize relief from pressure which Verbalize relief from
ko.” pleuritic chest & DM underlying pain or management could indicate pain or managing
pain, headache, condition of pain at a tolerable patient pain at a tolerable
-Retired
Patient had muscle/joint pain. level using the pain experiencing pain level using the pain
Seaman
verbalized pain as scale scale. Patient
7/10 using the pain Definition: -Check the patient's To monitor for the verbalized “Subong
V
scale Unpleasant breathing rate, patient’s daw indi na
sensory and characteristics, respiratory status. masyado kasakit
Accumulation of excess
Objective Cues: emotional including the Changes in kun mag ubo ko.
fluid in the lung space
experience involvement of patient’s breathing Daw 4/10 nlng”
between the membrane
T 36.2°C associated with accessory muscles pattern may GOAL MET.
lining.
PR 82bpm actual or when breathing, and indicate patient
RR 26cpm potential tissue Verbalize any other irregular suffering from Verbalize
V
BP 140/80 damage or understanding of pain breathing patterns. painful episodes understanding of
described in such management pain management
Interference in the
-Drain tube terms of damage techniques for pain Auscultate the lungs To establish a techniques for pain
function of fluid
insertion on the left relief and monitor for baseline. Gas relief. Patient had
production or re-
and CTT insertion adventitious breath exchange is stated that “Subong
absorption lead to fluid
on the right Source/ sounds. affected by rapid maginhawa ko
excess and build-up
Reference: and shallow dalum ukon
between the tissues.
Laboratories NANDA breathing punggan ko akon
Results: International, patterns, as well as tiyan mag ubo para
V
Nursing hypoventilation. indi sobra kasakit”
CXR: Diagnoses, Hypoxia, on the GOAL MET.
The presence of pleural
Bilateral moderate Eleventh Edition, other hand, is
fluid, which aids in the
pleural effusion Nettina, Sandra characterized by
with fissural M. (2003) breathing mechanism Exhibit pain an increased Exhibit pain
insuation on the Lippincott’s during lung expansion and management respiratory rate, management
right. pocket manual of relaxation, has abnormally behaviors during the employment behaviors during
nursing practice. increased. episodes of pain. of accessory episodes of pain.
CBC: 2nd edition.o muscles, nasal Patient
Hematocrit: 0.03 V flaring, diaphragm demonstrated how
breathing to do deep breathing
Blood Chemistry: Patient cannot effectively exercises as well as
Creatinine: 0.7 get enough oxygen. chest splinting. The
mg/dL patient had
Blood uric acid: V verbalized “Indi sya
12.2mg/dL Constantly monitor To detect tuod amo na kasakit
LDH:190 IU/L The body is unable to the patient's oxygen abnormalities in kun mag amo ko ni
Total protein: 5.9 eliminate carbon dioxide. saturation through a the patient’s kada mag ubo gale
g/dL pulse oximeter. oxygenation noh”
Globulin: 2mg/dL V status. Significant GOAL PARTIALLY
oxygenation MET
Strength: Oxygen excess or concerns are
-Strong family deficiency at the alveolar indicated by an
support. capillary membrane, oxygen saturation
-Cooperative resulting in impaired of less than 90% or
-Tells the concern carbon dioxide elimination a partial pressure
pertaining to his of oxygen of less
self. V than 80.

Weakness: S/S: Signs of basal rales -Constantly check To identify

-Poor health both lung fields the results of blood patient’s ABG
seeking behaviors chemistry and status. Elevated
V arterial blood gases Carbon dioxide
(ABG). levels and
Impaired Gas Exchange r/t diminishing levels
the altered supply of of oxygen may
 oxygen secondary to indicate
pleural effusion aeb basal respiratory
rales both lung fields. acidosis and
hypoxemia (low
level of blood
oxygen,
Source/Reference: particularly in the
Nettina, Sandra M. (2003) arteries)
Lippincott’s pocket manual
of nursing practice. 2nd
edition Place the patient in a To promote chest
high or semi- expansion for
Fowler's position optimized
with the head of the breathing and
bed elevated. decrease episodes
of pain.

-Conduct health To promote

teaching on pain independent
management management of
techniques such as pain during painful
deep breathing episodes.
exercises and visual Coughing and
distraction. deep breathing
exercises will help
the patient
evacuate
secretions from his
lungs. Visual
Imagery or Noise
distraction may
shift focus from
 pain and relieve
patient.
Dependent
Interventions

Administer oxygen To improve

therapy as oxygenation status
prescribed. of the patient.
Improved
oxygenation
promotes better
circulation and
decreased pain
episodes

Administer To promote
medications as pharmacologic
prescribed. effect of
medication.