ASSESSMENT

Subjective: Hirap huminga at hirap umubo, sobrang nakakapagod na.. as verbalized by the client Objective: Abnormal breath sounds: wet crackles, breath sounds: decreased pectoral whisper above the lesion area. Dyspnea; use of accessory muscles for respiration: elevated shoulders. decreased fremitus Restless Vital signs: BP - 80/60 hhmg Tº - 36.9 ºc RR - 26 cpm PR - 75 bpm

DIAGNOSIS
Ineffective airway clearance related to fatigue and poor cough effort as evidenced by abnormal breath sounds and dyspnea.

PLANNING
Short term goal: After an hour of nursing intervention, the client will be able to: Sustain respiratory rate within normal range: RR = 12-20cpm. Display decreasing amount of secretion. Allay restlessness. Minimize effort in coughing and breathing through proper breathing and coughing techniques.

INTERVENTIONS
Positioned patient to moderate or high back rest. Assessed respiratory rate. Noted chest movement; use of accessory muscles during respiration. Auscultated breath sounds; noted areas with presence of adventitious sounds. Nebulize patient as ordered. Documented respiratory secretions: character and consistency

RATIONALE
This position allows maximum chest expansion Provides a basis for evaluating adequacy of ventilation. Use of accessory muscles of respiration may occur in response to ineffective ventilation. Crackles indicate accumulation of secretions and inability to clear airways. Nebulization dilates bronchioles for easier breathing and expectoration of secretions.

EVALUATION
At the end of the shift, the client was able to display patency of airway as manifested by: Client s respiratory rate is within normal range: RR-19 bpm. Secretions decreased. Client s restlessness was alleviated and remained calm.

Taught patient coughing and breathing exercises.

Continuation NCM 1st Part
Rationale
Expectorations may be different when secretions are very thick. Breathing exercises This technique can help increase sputum clearance and decrease cough spasms. Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective. (Ackley & Ladwig, 2008, p.125-126)

ASSESSMENT Subjective: Sobrang nakakapagod, konting galaw o salita lang hinihingal na ko... as verbalized by the client. Objective: Fatigue Weakness Labored breathing: accessory muscles are used.

DIAGNOSIS Activity intolerance r/t severity of illness as manifested by general weakness, fatigue and respiratory difficulty.

PLANNING After 6-hours of nursing intervention, the patient will be able to: Tolerate performance of simple, day to day activities. Demonstrate proper breathing exercises. Decrease labored breathing by knowing how to use the respiratory muscles. Decrease fatigue

INTERVENTIONS RATIONALE Assisted with activities as needed. Encouraged frequent rest periods during the day.
Assistance is needed to decrease the respiratory efforts of the patient. Frequent rest period will help the patient relieve fatigue and maximize energy for necessary tasks. Prioritization is very helpful to prevent unnecessary tasks or movements which may use up client s strength. Keeping equipments close by or within reach of the patient will help decrease effort and use of energy.

EVALUATION Goal Met: The client was able to tolerate performance of simple activities without exhaustion, and labored breathing was decreased.

Encourage prioritization of necessary tasks. Kept equipments close by.

Taught patient cough/breathin g exercises such as purse-lip and diaphragmatic

Continuation of

nd 2

part NCM
Rationale Breathing exercises technique can help increase sputum clearance and decrease cough spasms. Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective.

Intervention breathing and asked him to return demonstrate to the nurse.

ASSESSMENT
Subjective Pt states a new person comes into his room every five minutes and he is not getting normal rest. Pt states that he feels tired and worn out. Objective Pt demonstrates facial expressions of irritation when a staff member enters the room. Pt was found sleeping or in a drowsy state when a staff member entered the room throughout the day.

DIAGNOSIS

PLANNING

INTERVENTIONS RATIONALE
Evaluate adequacy of nutrition and sleep patterns. Review medications for side effects. Teach strategies for energy conservation (e.g. sitting instead of standing during showers, store items at waist level) Encourage the client to keep a journal of activities, symptoms of fatigue, and feelings, including how fatigue affects the client s normal activities and roles. These assessments have all been shown to have good internal reliability. The journal can increase the client s awareness of symptoms and sense of control and facilitate communication with healthcare practitioners A commonly suggested treatment for fatigue is rest, although excessive sleep can aggravate fatigue. Inadequate nutrition can also contribute to fatigue

EVALUATION

Long Term: Fatigue R/T Disease Process and pharmacologi c reaction as evidenced by weakness and client s statement. Pt will verbalize increased energy and improved well being by discharge. Short term Pt will identify potential factors that aggravate and relieve fatigue within two days

Continuation of 3rd Part NCM
Intervention Assess severity of fatigue on a scale of 0-10 q 4 hours or PRN. Rationale
Certain medications (e.g., antihistamines, pain medications, anticonvulsants , chemotherape utic agents) may cause fatigue, particularly in the elderly Energy conservation strategies can decrease the amount of energy used.

Evalutation Goal Met: The client was able to tolerate performance of simple activities without exhaustion, and labored breathing was decreased

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