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ASSESSMENT Subjective: “pag ubo ko ng ubo nawawalan n ko ng ganang kumain” Objective: - weakness - Pale conjunctiva - Pale mucous membrane

- Poor muscle tone - Decreased capillary - Loss of appetite - Sore tonsils

NURSING DIAGNOSIS Risk for Imbalanced nutrition: less than body requirements related to persistent cough and mucus production

OBJECTIVES Short-term: After 30 minutes of nursing interventions the client will be able to: a.Verbalize understanding on the importance of proper diet. b.Enumerate foods to be included in his diet.

NURSING INTERVENTION - Plan with the client his desired meals and discuss eating habits, including food preferences, intolerances/ aversions

RATIONALE - For the client to be aware of the needed nutrients by his body to nourish himself. Also, giving sources of these nutrients helps the client to easier familiarize himself as to what foods he may include in his diet. - may have anegative effect on appetite or eating - Education provides ample information that the client may not be aware of, hence leading to the kind of eating habits and diet he

EVALUATION Short-term: Goal met. At the end of the nursing interventions, the client is able to understand the importance of proper diet. He is also able to select the meals he wants to eat, which are good sources of the nutrients needed by him.

- prevent or minimize unpleasant odor or sights - Educate the client regarding the importance of eating healthy foods and it’s benefits to his body.

Suggest ways that may assist the client in eating a.Junk foods have empty calories that provide no nutritional help to the client.A pleasant environment gives the client a relaxed feeling and will not spoil his appetite. Ensure pleasant environment.Caffeinated beverages may decrease the appetite and will make the client feel full easily. .demonstrate changes in his diet as manifested by proper food selection .Instruct the client to avoid junk foods. the client will be able to: a.is following. Goal not met because of lack of time .demonstrate adequate weight gain . b. Long-term: After 1 day of nursing interventions. Long-term: Goal met. the client was able to: a. And proper positioning reduces the risk of aspiration and heartburn. Facilitate proper positioning . the client will be able to: a. .Instruct the client to avoid caffeinated beverages.demonstrate changes in his diet as manifested by proper food selection After 1 week of nursing interventions. After 1 day of nursing interventions. .

. Too much weight gain..To provide nourishment to the client that keeps both of them healthy.Encourage the client to maintain the intake of the healthy foods needed by his body to achieve ideal body weight. such as diabetes mellitus. .Instruct the client to follow the prescribed number of servings of the meals included in his meal plan. which is out of the expected. . may bring about complications.Too much food intake is not good for the body. .

-Willingness to call on others for help -Emotional assistance provided by others . reports of and prognosis.Establishing rapport is essential to a therapeutic relationship and supports the client in selfreflection.Provide an atmosphere of acceptance. . Recognizing problems and sharing feelings is best brought about in an atmosphere of warmth and trust.ASSESSMENT NURSING DIAGNOSIS OBJECTIVES Coping as evidenced by often demonstrating ability to -Identify effective and ineffective coping patterns -Verbalize sense of control -Report decrease in negative feelings -Modify lifestyle as needed NURSING INTERVENTION . by substantial treatment.Provide factual information Social Support as concerning the evidenced diagnosis. RATIONALE . Stressed clients often misunderstand facts and require frequent clarification so that appropriate EVALUATION Goal not met because of lack of time Subjective: Risk for “nahihiya akong ineffective lumapit sa ibang Coping tao dahil dito sa ubo ko” Objective: -depression -self-destructive feelings -paranoia and loss of contact with real world -hopelessness -impulsiveness .Factual information serves as a foundation for Patient to explore feelings and alternative coping strategies.

Present and past coping status assists both Patient and him wife in capitalizing on successful methods. personal achievement. identifying ineffective strategies. Give him as many opportunities as possible to make decisions/choices for himself. . . and developing new skills more appropriate to the present situation. . Also determines risk for .Explore with his previous methods of dealing with life problems. Having valid information helps relieve stress.Arrange situations that encourage him autonomy. and self-esteem.Enhances a sense of control. .conclusions can be drawn.

.Assessing family interaction serves as a basis for identifying Patient’s support systems or lack thereof.inflicting selfharm. .Observe the degree of family support. perceptions.Open. .Assists to develop appropriate strategies for coping based on personal strengths and previous experiences. . Improves selfconcept and sense of ability to manage stress. nonthreatening discussions facilitate the identification of causative and contributing factors. .Encourage verbalization of feelings.Encourage to identify his own strengths and abilities. and fears. . .

Identifying specific strategies such as praise and encouragement during rehabilitation and healing will promote acceptance of change.Although adequate support systems may be available. Patient may not be using them or may be using them ineffectively. . .. and friends in the care and planning.Supporting patient in acknowledging changes in him appearance conveys acceptance and provides a foundation for him to begin to adjust .Family and friends are often willing but unsure how to help. .Discuss with concerned others how they can help.Involve wife. family. . .Determine barriers to using support systems.

report measurable increase in activity tolerance .participate willingly in necessary or desired activities .report measurable increase in activity tolerance .to conserve energy and reduce fatigue or weakness EVALUATION Goal met after 6 hours of nursing care management patient was able to: . NURSING INTERVENTION -adjusted activities .to prevent Overexertion .on oxygen therapy at 2 L/min NURSING DIAGNOSIS Risk for activity intolerance related to Imbalance between oxygen supply and demand OBJECTIVES That after six hours of nursing care management my patient will be able to: .assist with activities and monitored client’s use of assistive device . .Teach methods to increase activity levels gradually and plan care to carefully balance rest periods with activities .be free of any aggrevation of illness.have an RR of 22 cpm from 27 cpm .decreased RR from 27 cpm to 16-20 cpm .helps to minimize frustration and rechannel energy .assist client in learning and demonstrating appropriate safety measures RATIONALE .ASSESSMENT Subjective: “paminsan minsan pakiramdam ko nang hihina ako” Objective: -weakness -restless -RR of 27 cpm -breathes with much exertion and with the use of accessory muscles.felt a little relief when provided with nebulization .provide positive atmosphere while acknowledging difficulty of the situation for the client .participate willingly in necessary or desired activities .to prevent injuries .to protect client from injury .

Teach and supervise effective coughing techniques.Teach the client to maintain adequate hydration by drinking 8 to 10 glasses of fluids each day (if not contraindicated) and increasing the humidity of the ambient air .Proper coughing techniques conserve energy. reduce airway collapse and lessen client’s frustration. .Hydration helps to reduce secretions therefor improving the supply and demand of oxygen. .give client information that provides evidence of daily/weekly progress..to sustain motivation . . .

and cyanosis OBJECTIVES NURSING INTERVENTION RATIONALE .to know what possible condition the patient is experiencing .Increased RR – 27 . crackles.Encouraged deep absence symptoms controlled of respiratory breathing distress exercise.With circum oral cyanosis .Assessed Within 15 mins respiratory status of duty. Long Term Pt. wheezing. within normal limits and having .Prompt recognition of deteriorating respiratory function can .With wheezes .Regularly monitor the client’s respiratory rate and pulse . .Elevate the head ventilation and of the bed 45○ adequate (semi-fowler’s) oxygenation position. and cyanosis NURSING DIAGNOSIS Impaired gas exchanged related to retained secretions as evidenced by tachycardia.It maximize lung expansion thus sustain open airway .Advised the pt to keep calm during episodes of breathing difficulty .With nasal flaring.Auscultated lung fields Long Term After 1 day Pt will demonstrate improvement in . Short Term . tachypnea. wheezing. crackles.to prevent aggravation of the disease EVALUATION Short Term Goal partially met.Abdominal breather With crackles . was able to verbalize in understanding of the disease and its course of treatment.Serves as baseline data for any further complication . After 3 days Pt will be able to verbalize understanding regarding factors that would contribute to exacerbation of disease .Cardiac Rate – 108 .ASSESSMENT Subjective: “Hirap akong huminga” Objective: .It promotes optimal chest expansion . difficulty of breathing will be lessened.

Provide a fan if the client perceives a benefit from the moving air.Environmental changes may lessen the client’s perception of suffocation. ABG results. open doors and curtains and limit the number of people and unnecessary equipment in the room. .During episodes. and manifestations of hypoxia or hypercapnia. . Excessive increases in o2 (55% to 70% Flow) may diminish respiratory drive and increases carbon dioxide retention further. .Oxygen corrects existing hypoxemia. .Administer low flow oxygen therapy (1 to 3 L/min or 24 % to 31% Flo2) as needed via nasal prongs or a highflow venture mask. Report significant changes or lack of response promptly.oximetry. . reduced potentially lethal outcomes.

. .Encourage the use of breathing retraining and relaxation technique.A feeling of self control and success in facilitating breathing helps reduced anxiety..

Monitor lung sounds every 4-8 hours and before and after coughing episodes.ASSESSMENT Subjective “Nahihirapan ako huminga” Objective .Precipitators of allergic type or respiratory reactions that can trigger or exacerbate onset of acute episode .Rhonchi present in the large airways may impair patency.Use of accessory muscles noted .Keep environmental pollution to a minimum .Productive Cough .Dyspnea .Assessed respiratory status RATIONALE .Increased RR – 27 . elevate head of the bed .to know what possible condition the patient is experiencing .With wheezes NURSING DIAGNOSIS Ineffective airway clearance related to increased production of secretions OBJECTIVES After 2 hours of nursing interventions. the patient was able to demonstrate behaviors to improve airway clearance. the client will demonstrate behaviors to improve airway clearance like cough effectively and expectorate secretions.Facilitates respiratory function by gravity .Abdominal breather With crackles .g. cough effectively and expectorate secretions.Auscultated lung fields . NURSING INTERVENTION . e. .Assist patient to assume position of comfort. EVALUATION After 2 hours of nursing interventions.Serves as baseline data for any further complication . .Cardiac Rate – 108 .

Teach and supervise effective coughing techniques..Hydration helps to reduce secretions. if needed. . .Chest physical therapy techniques use forces of gravity and motion to facilitate secretion removal.Teach the client to maintain adequate hydration by drinking 8 to 10 glasses of fluids each day (if not contraindicated) and increasing the humidity of the ambient air.Perform chest physical therapy. . and instruct the client and significant others in these techniques.Proper coughing techniques conserve energy. . . . reduce airway collapse and lessen client’s frustration.

Reassess the condition of the oral mucous membranes and perform or offer oral care every 2 hours.. . oral care removes them. .Thick secretions line the mouth when the client coughs.