Professional Documents
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NURSING PROBLEM #1
Subjective:
Nakukurihan ak magginhawa. as verbalized.
Assessment
Nursing Diagnosis
Scientific Rationale
Objective:
Restlessness
Tachypnea at 28cpm
Tachycardia at 107bpm
Pallor noted
Capillary refill: 4sec
O2 Sat. at 87-88%
Impaired Gas Exchange related to altered oxygen supply
(obstruction of airways by secretion) as evidenced by restlessness
and tachypnea at 28cpm
Entry of noxious particles or gases to the lungs
Release of mediators
Chronic inflammation
Airflow limitations
Restlessness
Tachypnea at 28cpm
Tachycardia at 107bpm
Pallor noted
Capillary refill: 4sec
O2 Sat. at 87-88%
Reference: Pathophysiology by Gold, 4th edition p.345
Nursing Interventions
and
Scientific Rationale
Evaluation
NURSING PROBLEM #2
Subjective:
Masuol ak dughan, ak likod, pati ak tiyan! as verbalized.
PRS = 8
Assessment
Nursing Diagnosis
Objective:
Facial grimace
Restlessness
Guarding behavior
Frequent position changes
Acute Pain related to tumor effects, invasion of adjacent
structures, toxicities associated with medication therapy
Long-Term Goal:
After 5 days of nursing interventions, the client will be free from
experiencing pain.
Objectives/Planning
Nursing Interventions
and
Scientific Rationale
Short-Term Goal:
After 8 hours of nursing interventions the client will:
-state 3 ways of relieving pain such as imagery, application of hot
and cold compress and therapeutic touch.
-report decrease of pain scale from 8/10 to 5/5.
Nursing Interventions
Scientific Rationale
Independent:
-Encourage patient to verbalize -Promotes cooperation from the
about pain.
client. (Fundamentals of
Nursing by Taylor 5th e.
p.1216)
-Provide comfort measures
-This calms and soothes the
such as deep breathing
patient. (Fundamentals of
exercises
Nursing by Taylor 5th e.
p.1216)
-Encourage divertional
-To divert attention from pain.
activities (TV/radio,
(Fundamentals of Nursing by
socialization with others,
Taylor 5th e. p.1216)
imagery)
-Provide application of hot and -To relieve pain in the muscle
cold compress.
area. Maternal and Child Health
Nursing 5th e. by Pilliteri page
547)
-Provide therapeutic touch.
-To promote feeling of comfort.
(Maternal and Child Health
Nursing 5th e. by Pilliteri page
547)
-Monitor Vital signs.
-An information baseline
comparison from previous data.
(Manual of Nursing Procedures
Vol. I by Locquiao, Cruz,
Arguelles and Lontoc page 122)
-Position patient on moderate
-To promote comfort and
high back rest or in
maximum lung expansion
comfortable position
Collaborative:
-Administer analgesics as
ordered.
NURSING PROBLEM #3
Subjective:
Ginhahapo ak tas gin-inubo liwat! as verbalized.
Assessment
Nursing Diagnosis
Scientific Rationale
Objectives/Planning
Objective:
Increase in respiratory rate of 28cpm
Shortness of breath (orthopnea)
Dyspnea
Use of accessory muscles in breathing
Altered chest excursion
Nasal flaring
Increased anterior-posterior diameter
Ineffective Breathing Pattern related to presence of secretions
AEB productive cough and dyspnea associated with lung cancer
Presence of secretions in the bronchi will result into a blockage of
air that will enter the body and thus producing insufficient air
needed by the body. And inability to maintain clear airway. This
obstruction is further heightened by bronchospasm due to the
contraction of the smooth muscles in the bronchi. This is caused
by parasympathetic stimulation of the muscarinic2 receptors as
well as by chemical mediators released.
Reference: http://www1.us.elsevierhealth.com/SIMON/Ulrich/
Constructor/diagnoses.cfm?did=31
Long-Term Goal:
After 2-3 days of nursing intervention, patient will establish
normal breathing pattern.
Short-Term Goal:
After 8 hours of nursing intervention, patient will be able to
Nursing Interventions
and
Scientific Rationale
Evaluation
Short-Term Goal: ACHEIVED
After 8 hours of nursing intervention, patient verbalized
understanding and demonstrated proper deep breathing technique
to facilitate proper oxygenation to alleviate hyperventilation.
NURSING PROBLEM #4
Subjective:
Di ko kam ma-entertain kay nanluluya ak!as verbalized.
Assessment
Nursing Diagnosis
Objective:
Weak in appearance.
Cannot perform ADLs alone.
With limited range of motion.
Muscle strength:
Left upper extremity=5; Right upper extremity=5;
Left lower extremity=4; Right lower extremity=2
Muscle weakness ---> Chest pain, back pain, abdominal pain --->
reduction of muscle strength ---> impaired ability to maintain
Scientific Rationale
Objectives/Planning
Long-Term Goal:
After 5 days of effective nursing interventions, the patient will be
able to maintain activity level within capabilities as evidenced by
normal vital signs during activity, as well as absence of weakness,
pain, and difficulty accomplishing tasks.
Short-Term Goal:
After 8 hours of effective nursing interventions, the patient will
be able to do ADLs alone and to participate in self-care
activities.
Nursing Interventions
> Monitor vital signs and
record.
Nursing Interventions
and
Scientific Rationale
output
Scientific Rationale
> To help determine patients
current health status and
evaluate effectiveness of
nursing intervention rendered.
> To evaluate the proper
functioning of his kidney in
relation to his present condition.
> To determine the capacity of
patient in doing ADLs.
> To know if there is any
changes on patients condition
specifically on physical aspect.
> To minimize fatigue and to
evaluate his capabilities in
doing such.
> To maximize full strength.
Evaluation
NURSING PROBLEM #5
Assessment
Subjective:
Wara ak gana kumaon. Ditoy la ak nakakaon. as verbalized.
24 hours dietary recall
Breakfast: 1 slice of bread and coffee
Lunch: Egg, rice, 1 spoon vegetable
Dinner: Rice and 1 pc of fish
Objective:
Small body frame
Weak in appearance
Pale conjunctiva and mucous membrane
Dry skin
Loss of appetite
Muscle wasting
Nursing Diagnosis
Scientific Rationale
Reference: http://nurseslabs.com/tag/imbalanced-nutrition-lessthan-body-requirements/
Long-Term Goal:
After 1 week of nursing intervention the client will demonstrate
progressive weight gain toward goal.
Objectives/Planning
Scientific Rationale
1. All factors that can affect
ingestion and digestion of
nutrients.
Nursing Interventions
and
Scientific Rationale
4.Prevent /minimize
unpleasant odors.
Evaluation