This action might not be possible to undo. Are you sure you want to continue?
Ineffective airway clearance related to excessive thickened secretions
Assessment Nursing Diagnosis Ineffective airway clearance related to excessive thickened secretions Rationale
Aspiration of bacteria in lower respiratory tract Bacterial invasion into the lungs and lower respiratory tract (trachea > bronchus > bronchioles Immune response triggered
Goals and Objectives After 30 mins of nursing interventions, the client will be able to: -demonstrate reduction of congestion with breath sounds clear, respiration noiseless, improved oxygen exchange - demonstrate behaviors to improve airway clearance.
Implementation Independent: • Elevate head of the bed, have patient lean on over bed table or sit on edge of the bed. Position with proper body alignment
Subjective: “Inuubo ako dahil ang dami kong plema”, as verbalized by the patient. Objective: • White to yellow green sputum • Expectorating cough • Abnormal breath sounds -There are crackles heard on the left lung and decreased breath sound on the right lung • V/S taken as follows: BP: 140/90 T: 36.5 C PR: 72 RR: 19
Lymphocytes produce cytokines
↑ WBC Release of chemical mediators Release of killer T-Cells, macrophages, phagocytes Migration to alveoli Killer T-Cells, macrophages, phagocytes and anti-bodies take effect to pathogens
Encourage or assist with abdominal or pursed lip breathing exercises.
Vasodilation and ↑ capillary permeability
Assist with measures to improve effectiveness of cough effort.
• Elevation of the bed After 30 mins of facilitates respiratory nursing interventions, the function by use of gravity. goals were partially met. The client were able to: -demonstrated • For optimal breathing reduction of pattern, lung expansion congestion with and improved gas breath sounds exchange clear, respiration • Provides patient with noiseless, some means to cope with improved oxygen or control dyspnea and exchange -demonstrated reduce air tapping. behaviors to airway • Coughing is most effective improve clearance. in an upright position after chest percussion. Hydration helps decrease the viscosity of secretions, facilitating expectoration. Using warm liquids may decrease bronchospasm.
Fluid shifting and edema
Increased fluid intake to • 2000 cc/day. Provide warm or tepid liquids.
Purulent exudate formation
Keep environmental • Precipitators of allergic type of respiratory reactions that pollution to a minimum like dust, smoke and can trigger or exacerbate feather pillows. onset of acute episode. Pace activities. Maintain • planned rest periods. To prevent fatigue
Filling of WBC in alveoli and the normally air Exudate/Fluid accumulation in alveoli
the body releases chemical mediators and killer T-cells leading to vasodilation.• Dyspnea Instruct patient to avoid • restrictive clothing It could prevent adequate respiratory excursion Cough with purulent yellowish Crackles Chest pain The patient has pleural effusion secondary to CAP. The. fluid shifting and formation of purulent exudates. . Thus. he experienced bacterial lower respiratory tract infection which triggered his immune system response. chest pain and crackles. The WBC fills/accumulates in alveoli which block the airway of the patient resulting to difficulty of breathing. In his case. coughing as a way of removing the obstruction. it results to inflammation and increase in WBC.
eupnea or normal good unlabored breathing 2. or cyanosis To provide relief of causative factors Purulent exudate formation Filling of WBC in alveoli and the normally air containing space • Administer prescribed respiratory medications such as: (a) Zithromax. the proper body breathing pattern.regular splinting techniques respiratory rate of 19 bpm and depth Dependent: Dependent: of respiration Administer O2 as • prescribed (4-10LPM) For management of underlying pulmonary condition. normal skin color breathing. macrophages. The patient was able improved gas to maintain exchange Elevate HOB or • To promote normal breathing pattern as have client sit up on physiological/ evidenced by: a chair psychological ease Encourage • To assist client in slower/deeper “taking control” of 1. normal skin color Implementation Independent: Rationale Independent: Evaluation Inflammatory response Lymphocytes produce cytokines ↑ WBC Release of chemical mediators Release of killer T-Cells. alignment lung expansion and goal was met.Assessment Subjective: “Nahihirapan akong huminga”. and 3.regular respiratory rate of 12-20 bpm and depth of • respiration After 30 minutes of nursing Position with • For optimal interventions. phagocytes and anti-bodies take effect to pathogens Vasodilation and ↑ capillary permeability Fluid shifting and edema 3. use of the situation unlabored pursed-lip breathing technique • Teach patient • To facilitate appropriate adequate clearance 2. eupnea or normal good respirations. • . of secretions coughing. respiratory distress. as verbalized by the patient. Objective: • Dyspnea • Tachypnea • Tactile fremitus is slightly increased on right lung • Cough with purulent discharge • Nasal flaring • Respiratory depth changes • Altered chest excursion • Use of accessory muscles • Cerebral hypoxia • CNS alteration • Increased anteroposterior chest diameter • Chest pain • Crackles • V/S taken as Nursing Diagnosis Ineffective breathing pattern related to inflammation of lower respiratory tract secondary to infection Rationale Aspiration of bacteria in lower respiratory tract Bacterial invasion into the lungs and lower respiratory tract (trachea > bronchus > bronchioles Immune response triggered Goals and Objectives After 30 minutes of • nursing interventions. the patient will be able to maintain normal • breathing pattern as evidenced by: • 1. phagocytes Migration to alveoli Killer T-Cells. macrophages.
follows: BP: 140/90 T: 36. oral Exudate/Fluid accumulation in alveoli (b ) Sinecod Forte 1tab TID. oral Partial occlusion of bronchi and alveoli Dyspnea Altered ventilation and diffusion Cough with purulent yellowish secretions Decrease oxygen level of blood that passes on the lungs Crackles Chest pain ↓ Alveolar O2 tension Venous blood entering pulmonary circulation passes unventilated area Ventilation and Perfusion mismatch Poorly oxygenated blood travels to the left side of the heart ↓ Circulating O2 Arterial hypoxemia Hypoxia Cerebral hypoxia CNS Alterations fatigue. irritability.5 C PR: 72 RR: 24 500 mg OD for 3 days. loss of appetite Altered Tissue Perfusion ↑ Oxygen demand Hyperventilation ↑ Heart Rate Difficulty of breathing and shortness of breath Use of accessory muscles ↑ Respiratory Rate .
Because of infection. Thus. Then. DOB. it results to vasodilation and fluid shifting. The patient will experience increase oxygen demand causing hyperventilation. WBC fills/accumulates in alveoli which partially blocks the airway of the patient resulting to difficulty of breathing. . In addition. the patient is experiencing lung compression leading to dyspnea. chest pain and crackles. the body triggers immune response causing inflmmation. This causes altered ventilation and diffusion leading to decreased oxygen perfusion because of poorly oxygenated blood. coughing as a way of removing the obstruction. increased heart rate. use of accessory muscles in breathing an increased RR.
-Facial grimace was seen rarely during visits. ↑ WBC Objective: • pain on RUQ area upon movement • Facial grimace • Abdominal Guarding • Restlessness • OFI: 1L/shift • Occupation: Merchandiser • Vital signs taken: -BP: 140/90 -RR: 24cpm -PR: 72 bpm Release of chemical mediators Vasodilation and ↑ capillary permeability Release of killer T-Cells.” as verbalized by the patient. Acute pain related to Accumulation of fluid in the pleural space Assessment Nursing Rationale Diagnosis Acute pain related to “ Medyo sumasakit Accumulation yung tagiliran ko of fluid in the kapag gumagalaw pleural space ako. phagocytes and anti-bodies take effect to pathogens • • Fluid shifting and edema • Helps in relieving pain and reducing stress Purulent exudate formation • Absence of facial grimace Absence of abdominal guarding • • Filling of WBC in alveoli and the normally air containing space • Increased OFI will Vital signs taken as enhance follows: metabolism and maintain the proper function of . -high back rest • Encourage to have adequate bed rest. -He was able to perform nonpharmacologic techniques to relieve pain such as: deep-breathing To provide comfort. phagocytes Migration to alveoli Killer T-Cells. • To distract attention. Encourage to increase OFI to 2L/shift. -instruct deep breathing exercise Painscale will be decreased into -quiet environment 5/10 • Encourage to have diversional activities like Verbalize usse of watching nontelevision. Subjective: Aspiration of bacteria in lower respiratory tract Bacterial invasion into the lungs and lower respiratory tract (trachea > bronchus > bronchioles Immune response triggered Goals and Implementation Objectives After 3hrs of nursing Independent: intervention. reduce tension and promote relaxation.repositioning Place patient on comfortable position. . macrophages.BP: 130/70 body/organs. met.deep breathing . -He was kept comforted at highback rest position. exercises and repositioning. pharmacologic techniques to relieve pain: . • Pain Scale: 7/10 Inflammatory response Lymphocytes produce cytokines -The client verbalized that the pain decreased to 5/10 from 7/10.3. macrophages.RR:20 cpm . • Rationale Evaluation • After 3hrs of nursing To promote pain interventions the management and to goal was partially alleviate pain. patient • Provide nonwill demonstrate or pharmacologic report the following management: condition/s: • Pain is relieved / -change of position controlled.
Ketorolac 30 .OFI to 2L/ shift mg q8 hours Vital signs will be on the patient’s accepted level: .PR: 75 bpm .• Exudate/Fluid accumulation in alveoli Dyspnea Maintain proper Dependent: nutrition and promote • Administer wellness.BP: 120/80 . . Cough with purulent yellowish secretions Crackles Chest pain • In addition. medications as ordered.PR: 79 bpm • To reduce pain by inhibiting gastric acid secretions.RR: 20 cpm . . the patient is experiencing further accumulation of fluid in the pleural space causing chest pain.
normal respiratory rate of 20bpm. the goal was partially met. feel weak and unable to weakness and perform activities. He has absence of pneumonia and pleural shortness of effusion causing him pain which leads him to breath.” as verbalized by the patient. • Refrain from performing nonessential procedures INDEPENDENT • to reduce cardiac workload After 3 days of nursing intervention. diagnostic procedures. decreased blood pressure during activity (130/70). weakness and fatigue. verbalize and utilizes energy conservation techniques • Encourage verbalization of feelings regarding limitations.5 C PR: 72 RR: 24 • to reduce energy expenditure . and absence of shortness of breath. fatigue. • • Encourage active ROM exercise TID • Assist with ADL as indicated • V/S taken as follows: BP: 140/90 T: 36. and activities. 2. Maintain activity level The patient has activity within intolerance because of capabilities by his change in physical normal heart condition leading to rate. to prevent overexerting the heart and to promote attainment of short-range goals to maintain muscle strength and joint range of motion 1. blood decrease energy to pressure during perform desired activity. and meals. • to promote rest Objective: • • Exertion discomfort or dyspnea Verbal report of fatigue or weakness 1.4. • • Progress activity gradually. verbalized and utilizes energy conservation techniques “Nahihirapan ako tumayo. The patient were able to: • Acknowledgement that living with activity intolerance is both physically and psychologically aids coping. 2. the patient will be able to: • Encourage adequate rest periods. medyo nanghihina ako at masakit ang tagiliran ko. After 3days of nursing intervention. Activity intolerance related to weakness and pain Assessment Nursing Diagnosis Rationale Goals and Objectives Nursing Interventions Rationale Evaluation INDEPENDENT Subjective: Activity intolerance related to generalized weakness and pain Activity intolerance is a state in which a person has insufficient physical or psychological energy to endure or perform desired physical activities. Maintain activity level within capabilities by normal heart rate of 79 bpm. especially before ambulation.
elevation of head of bed while patient gets out of bed. chair in bathroom. allowing more prolonged activity.• Avoid doing for patient what he/ can do for himself/herself • to increase patient’s selfesteem • They reduce oxygen consumption. hall rails) . .Distributes work to different muscles to avoid fatigue .Standing requires more work .Allows enough time so not all work is done in a short period of time > to avoid bending and reaching > because energy is needed to digest food • to conserve energy and prevent injury from fall • Teach energy consumption techniques such as: -Sitting to do tasks -Changing position frequently -Working at an even pace -Storing frequently used items within easy reach -Resting for at least 1 hour after meals before a new activity • Teach appropriate use of environmental aids (bed rails.
• • Establish semblance of “normal” daily routine with periods of activity. the patient will achieve optimal amounts of at least eight hours of sleep as evidenced by: . Implementation INDEPENDENT • Maintain environment conducive to sleep/rest • Assist patient in observing any previous bedtime ritual • Instruct relatives to provide nursing care such as back rub. putol-putol nga ang tulog ko”. rest. the goal was met. • . comfortable position and relaxation techniques • Organize nursing care • Attempt to allow sleep for sleep cycles of at least 90 minutes.5. apat na beses ako umihi sa gabi.Rested appearance and improvement in sleep pattern. as verbalized by the patient. bedtime care. pain relief. Rationale INDEPENDENT • • to promote sleep and rest to promote relaxation Evaluation • to promote rest and relaxation • to promote minimal interruption in sleep/rest Experimental studies have indicated that 60-90 minutes are needed to complete one sleep cycle and the completion of an entire cycle is necessary to benefit from sleep. The patient was able to achieve optimal amounts of at least nine hours sleep as evidenced by rested appearance and improvement in sleep pattern. ihi kasi ako ng ihi. Sleep Pattern Disturbance related to frequent nocturnal urination Assessment Nursing Rationale Goals and Diagnosis Objectives Subjective: “Nagigising ako sa gabi. After 3 days of nursing intervention. Adherence to previously established patterns/routines minimizes energy After 3 days of nursing intervention. Objective: -Fatigue -Weakness -Restlessness Sleep Pattern Disturbance related to frequent nocturnal urination The patient was interrupted in her sleep because she felt the urge of urination at night.
required for adaptation and disruption in biological rhythms. . • soporifics to induce sleep and avoid stimulants to prevent stimulation which interferes sleep • Napping can disrupt normal sleep pattern • Discourage pattern of daytime naps unless deemed necessary or part of usual pattern. • Provide soporifics such as milk and avoid stimulants such as caffeine or cola beverages as needed.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue listening from where you left off, or restart the preview.