NURSING CARE PLAN CUES Subjective: Mag-ubo-ubo ko usahay ug di kaginhawa as verbalized by the patient Ineffective airway clearance RT retained

secretions AEB presence of rales and crackles on both lung fields. NURSING DIAGNOSIS OBJECTIVE Short Term: The patient will be able to establish and maintain airway patency AEB absence of respiratory distress Long Term: The patient will be able to demonstrate improve airway clearance AEB reduction of congestion with breath sounds clear and improved RR. INTERVENTION 1. Monitor and record vital signs . 2. Assess patients condition. 3. Monitor respirations and breath sounds, noting rate and sounds. 4. Position head properly Position appropriately and discourage use of oil-based products around nose. 5. Auscultate breath sounds and assess air movement. 6. Encourage deep breathing and coughing exercises. 7. Elevate head of bed and encourage frequent position changes. 8. Keep back dry and loosen clothing 9.Instruct patient have adequate rest periods and limit activities to level of activity intolerance. 10. Give expectorants and bronchodilators as ordered. RATIONALE 1. To obtain baseline data 2. To know the patients general condition 3. To determine respiratory distress and accumulation of secretions. 4. To open or maintain open airway. To prevent vomiting with aspiration into lungs. 5. To ascertain status and note progress. 6. To maximize effort 7. To promote maximal inspiration, enhance expectoration of secretions in order to improve ventilation 8.To promote comfort and adequate ventilation 9. Rest will prevent fatigue and decrease oxygen demands for metabolic demands 10. To further mobilize secretions and to clear airway when secretions are blocking the EVALUATION Short-tem: Goal fully met. Pt. was able to maintain patent airway without respiratory distress. Long-Term: Goal partially met; Rales are still present on both lung fields.

Objective: >Patient manifested a non-productive cough > presence of rales upon auscultation >(+) DOB with pale, nail beds

NURSING CARE PLAN CUES Subjective: Murag luspad lantawon akong mga tiil as verbalized by the patient Ineffective tissue perfusion r/t decreased cardiac output NURSING DIAGNOSIS OBJECTIVE Short Term: After 8 hours of nursing interventions the patient will demonstrate behaviors to improve circulation 1. Establish a quiet environment. 2. Elevate head of bed. 3. Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides. 1. A quiet environment reduces the energy demands on the patient. 2. Elevation improves chest expansion and oxygenation. 3. Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation. 4. Oxygenation increases the amount of oxygen circulating in the blood and, therefore, increases the amount of available oxygen to the myocardium, decreasing myocardial ischemia and pain. 5. Assessment establishes a baseline and detects changes that may indicate a change in cardiac output or perfusion. 6. Anginal pain is often precipitated by emotional stress that can be relieved nonINTERVENTION RATIONALE EVALUATION Short-tem: Goal unmet. Pt was not able to demonstrate the behaviors to improve circulation; paleness is still visible on both lower extremities.

Objective: Long Term: >with nail beds and > (+)chest pain > (+) DOB >pt. experiences fatigue >With pitting edema on both legs >altered BP readings After 3 days duty and applying appropriate nursing interventions the patient will be able to demonstrate increased perfusion as individually appropriate.

Long-Term: Goal unmet. Pt. was not able to demonstrate increased perfusion since CRT is still >3 secs. Plae and edematous lower extremities

4. Provide oxygen and monitor oxygen saturation via pulse oximetry, as ordered and as necessary.

5. Assess cardiac and circulatory status.

6. Monitor cardiac rhythms on patient.

7. Teach patient relaxation techniques

and how to use them to reduce stress. 8. Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction. 9. Reposition the patient every 2 hours. 10. Instruct patient on eating a small frequent feedings

pharmacological measures such as relaxation. 7. In some case , the chest pain may be more serious than stable angina.

8. The patient needs to understand the differences in order to seek emergency care in a timely fashion. 9. To prevent bed sores

10. To prevent heart burn and acid indigestion