A.

Impaired gas exchange related to decreased lung function and respiratory distress

Assessment Diagnosis Planning Intervention Evaluation

Subjective cues: Impaired gas After 4 hours of 1. Auscultate lung The goal met after 4
exchange related to nursing intervention sounds at least every hours of nursing
“Lagi akong pagod decreased lung the client will be able 2 to 4 hours. Listen intervention the client
kahit wala naman ako function and to: for crackles and was able to:
masyadong respiratory distress. wheezes. Verbalized
ginagawa, Verbalize understanding of
nahihirapan din ako Impaired gas understanding of Rationale: Patients oxygen and other
huminga kahit minsan exchange occurs oxygen and other with respiratory therapeutic
nakaupo lang ako. when lungs struggle therapeutic problems may have interventions,
Pakiramdam ko may to efficiently transfer interventions wheezes, and participates in
nakaupo sa dibdib ko” oxygen and remove crackles. Changes or procedures to
as verbalized by the carbon dioxide, Participates in worsening in these optimize oxygenation
patient leading to respiratory procedures to lung sounds may and in management
distress and tissue optimize oxygenation indicate a decline in regimen within level
Objective cues: damage, potentially and in management ventilation. Often lung of capability/condition
resulting in organ regimen within level sounds contribute to as evidenced by heart
-Restlessness failure. of disclosing the source rate (60-100 bpm)
Etiology: Impaired capability/condition, of poor ventilation. and oxygen saturation
-abnormalbreathing gas exchange due to Lessen the breathing within normal range
such wheezing and COPD, asthma, difficulties and be 2. Instruct patient to <90% (normal: 95%
crackles pneumonia, and able to feel relaxed limit exposure to to 100%), the patient
-90% oxygen ARDS can result from persons with find ease to breath
saturation airways constriction, respiratory infection and felt relaxed.
inflammation, and
-32 bpm respiratory Rationale: To reduce
environmental factors,
rate potential spread of
requiring treatment.
droplets between
patients.
3. Assess
respirations:
quality, rate, pattern,
depth and breathing
Effort

Rationale: To
Administer of
supplemental oxygen
can improve gas
exchange by
increasing the partial
pressure of oxygen in
the blood

3. Monitor oxygen
saturation
continuously, using a
pulse oximeter

Rationale: An oxygen
saturation of <90%
(normal: 95% to
100%) or a partial
pressure of oxygen of
<80 (normal: 80 to
100) indicates
significant
oxygenation
problems.

4. Monitor for
alteration in BP and
HR per minute.

Rationale: BP, HR,

and respiratory rate
all increase with initial
hypoxia and
hypercapnia.
However, when both
conditions BECOME
severe, BP and HR
decrease and
dysrhythmias may
occur. oxygenation
problems.

5. Position patient in a
sitting position with a
calm environment

Rationale: to reduce
the pressure on his
chest and improve his
breathing, and
oxygenation and
reduce the workload
on the respiratory
system and relax
environment patients
can help patients to
relax.

6. Advice the patient

to side-lying position
while sleeping

Rationale: to improve
respiratory and
pulmonary circulation
 B. Ineffective airway clearance related to increased mucus production and airway obstruction
Assessment Diagnosis Planning Intervention Evaluation
Subjective cues: Ineffective airway After 4 hours the 1. Assess the airway After 4 hours of
“Nahihirapan ako clearance related to client will be able to for patency. nursing intervention
huminga at hindi ko increased mucus the client was able to
mailabas ang aking production and airway Improve the patent Rationale: improved patent
plema”, as verbalized obstruction. airway by managing Maintaining the airway in managing
by the patient secretions with airway is always first secretions as
Ineffective airway hydration, effective priority, especially in evidenced by:
Objective cues: - clearance refers to a coughing and the cases of trauma, or
Unproductive cough condition where the ability to cough out lesion in the mouth.
with thick, greenish- normal process of secretions. Well-hydrated, which
yellow sputum clearing the airway helps in thinning the
through coughing or 2. Auscultate lungs mucus and making it
- Shortness of breath infections difficulty for presence of easier to cough out.
with a 90% oxygen breathing, normal or adventitious
saturation level and breath sounds: Performed effective
presence of wheezing Etiology: a condition *Decreased or absent coughing techniques,
sound that compromises a breath sounds. which helps in
patient's airway, blood Wheezing clearing the airways.
- 32 bpm respiratory flow, or respiratory
rate effectiveness. Airway Rationale:
compromise can be These may indicate Breath sounds have
caused by a physical the presence of a less crackle sound
blockage, such as a mucus plug or other and oxygen saturation
foreign body lodged in major airway levels have improved
the airway obstruction. from 90% to 94% and
decreased respiratory
congestion in the 3. Position the patient rate from 32 bpm to
chest. Ineffective in a semi-Fowler 28 bpm
airway clearance can position to
result in complication promote lung Reported feeling
expansion and better and more
s such as pneumonia improve oxygenation. comfortable, indicated
or respiratory failure if that the nursing
left untreated. Rationale: interventions were
to promote lung effective in managing
expansion and the airway clearance
improve oxygenation. issue.
which may indicate
partial airway
obstruction.

4. Monitor the
patient's oxygen
saturation levels and
respiratory rate to
assess the
effectiveness of the
intervention.

Rationale:
To improve breathing
and promote drainage
of secretions.

5. Encourage the
patient to drink plenty
of fluids to help
thinning and mo the
mucus and make it
easier to cough out.

Rationale
Being dehydrated or
even sleeping can
cause the phlegm to
move slower and
become thicker than
usual

6. Encourage the
patient to perform
effective coughing by
deep breathing
techniques, The first
cough loosens the
mucus and moves it
through the airways.
The second and third
cough enables you to
cough the mucus up
and out.

Rationale
To help the patient
use that technique
and easier to spit out
the phlegm.

7. Administer
bronchodilators and
expectorants as
ordered

Rationale
to help loosen and
clear secretions.
 8. Advice the patient
to gargle fresh water
with salt

Rationale
will help reduce the
amount of mucus and
phlegm at the back of
the throat, lessening
your need to cough.

C. Imbalanced nutrition: less than body requirements related to loss or appetite and weight loss
 Assessment Diagnosis Planning Intervention Evaluation

Subjective cues: Imbalanced Nutrition: Short term: 1. Provide patient a After the nursing
related to less than plan of healthy meal intervention the
“Nakakaligtaan ko po body requirements At the end of 4 hours patient was able to:
kasi kumain sa and loss of appetite of nursing intervention Rationale:To
tamang oras dahil sa as evidenced by the patient will be encourage the patient Determine the foods
aking trabaho” as weakness and fatigue able to: to eat 3x a day that needed to be
verbalized by the consumed, like fruit
patient Imbalanced nutrition Determine the foods 2.Instruct patient to and vegetables.
refers to an that need to be avoid caffeinated
individual's consumed. beverages Identified unhealthy
inadequate or unmet foods to be avoided,
Objective Cues: body requirements, Understand the Rationale:This like canned food and
resulting from importance of beverage can spoil ready-to-eat food.
Weight-45kg decreased appetite or nutrition for the body. the patient’s appetite
inadequate nutrient by decreasing Understood the
Height-161cm hunger importance of
absorption, causing
weakness and nutrition for the body
BMI-17.3 underweight 3.Explain to the to have a healthy
fatigue.
patient the lifestyle and
-Weight loss importance of verbalized that he
Etiology: Imbalanced nutrition that the body needs to eat three
-Weakness and
nutrition, causing needs by eating times a day.
fatigue
body requirements vegetables.
-Pallor and appetite loss, is
complex and Rationale:To
-dry lips influenced by multiple maintain the body
factors. Proper weight and balance
-consuming unhealthy nutrition and a healthy nutrition
foods like canned lifestyle prevent and
goods, noodles. 3. To replace the lack
treat it.
Coffee. of nutrition in the body

Rationale: To replace
the lack of nutrition in
the body

4.Advice the patient

to eat foods or snacks
like banana, sweet
potatoes.

Rationale: To less
the consumed time
and improved patient
hydration

5.Advice patients to
increase fluid intake
and bring containers
everyday.

Rationale: To
promote bonding of
the family and
increase confident

6.Advice the
significant other to eat
together

Rationale: To provide
energy supplement

7.Encourage patients
 to sleep 7-9 hours a
day and .Administer
Vitamin C as ordered
by physician.

Rationale: to contain
energy of the patient

D. Knowledge deficit related to tuberculosis transmission, prevention and treatment

 Assessment Diagnosis Planning Intervention Evaluation

Subjective cues: This can lead to After 4 hours of

avoidance behaviors At the end of 2-4 1. Assist the patient's nursing intervention
““Pag kumakain kami such as social hours of Nursing understanding of the the patient was able
lumalayo ako sa mga distancing, isolation, Intervention the disease. to:
tao sa bahay kasi and excessive patient will be able to
takot ako baka handwashing as a decrease anxiety by Rationale: Identified the
mahawa ko sila” means of preventing diverting the attention preventive measure
transmission. to engaging hobbies To determine what practice that helps to
Objective cues: like watching TV, type of patient needs prevent the spread of
The fear of infecting sewing, and exercise. to be educated about infections.
Insecurity in others can or emphasize the
relationship significantly impact an disease,
individual’s quality of To understand that Verbalize willingness
-Prefer to be alone the disease is not 2. Talk to the patient to participate in
life, social
contagious when the with a slow tone of medication therapy by
interactions, and
patient under TB voice and encourage understanding the
overall mental health.
medication/ him to ask questions importance of
maintenance that he is not familiar medication
Etiology: Cognitive-
with. Help the patient
behavioral, social
to express feelings.
learning, and
evolutionary theories Rationale:
explain anxiety in
disease, originating To provide
from negative information and
thoughts, behaviors, correct the wrong
and adaptive presumption about
responses. Treatment the disease. And
involves patient can
understanding and communicate with
managing anxiety. others without
hesitant.

3. Assess the patient

hobbies and discuss
them with family to
provide materials

Rationale

For the patient

occupying time to
decrease anxiety.

4. advise the patient

to cover the mouth
while sneezing and
coughing

Rationale:

To avoid the spread

of bacteria from
disease

5. Provide preventive
measures like using a
facemask, an alcohol
scrub, handwashing
before and after
eating, or avoiding

contact with others.

Rationale:

To have the patient

self-disciplined with
his contagious
disease

6. Instruct the patient

to sleep in a separate
room.

Rationale: keep
patients separate
from other people
while they receive
medication therapy.

7. Advise the patient

and family to limit the
visits.And contact with
other colleagues as
necessary.

Rationale:

To minimize the
spread of infection in
the area and fa 8.
Provides patient
information on how to
take the prescribed
medication ordered
by the physician.

Rationale

To help the infection

reduce with the
duration of medication
and follow-up.

9. Educate the patient

that when under
maintenance of
medication the
contagious disease
can be reduced

Rationale

To the patient have

an idea about the
disease and reduce
anxiety

10. Provide patient

tissue napkin or fluid
container for
collection of phlegm

Rationale

To patient have
discipline in his own
secretion fluid.