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#
- Due to To - AT THE END
%&
#
$
Goal
>³Masakit yung Impaired limitation of facilitate OF THE $
Assess respiratory $
Flaring of the partially
kamay ko´. respiratory oral fluid the SHIFT... quality, rate, depth, nostrils, dyspnea, met.
function
related intake to 500 mainte-
#
$ Patient¶s effort and pattern. use of accessory Patient¶s
>´ medyo to immobility mL /day and nance of a RR will muscles, tachypnea RR
masakit din stasis of prolonged supply of decrease from are all signs of decreased
yung tiyan ko´. secretion immobility oxygen to 30 cpm to 12- severe distress that from 30
due to all body 20 cpm. require immediate cpm to 25
> ³masakit condition of cells intervention.
cpm.
yung patient that
lalamunan ko´. even at rest c '   &


the $ Taught the use of $
Promotes better
> ³ Medyo manifestation non pharmacologic lung expansion and
nahihilo ako´. of the techniques (CPT, improved gas
disease DBE, coughing exchange.
occurs. exercise positioning
"
on high fowler¶s
> 8/10 pain position).
scale in left (
- Pain on the To
(
$ Patient¶s
%

(
$
Goal not
arm Chronic and hand may be promote pain on the
$ Perform a $ Pain is a met, patient¶ s
> 5/10 pain acute pain due to good right hand will comprehensive subjective pain on left
scale in the related to edema. Pain hygiene decrease from assessment of pain experience and hand
abdomen stimulation of in the left and 8/10 to 5/10. to include location, must be remained
> 3/10 pain nerve endings lower physical characteristics, described by the 8/10.
scale in throat secondary to quadrant comfort.
(
$ Patient¶s onset, duration, client in order to (
$ Goal
(+) facial edema on the may be due pain on the frequency, quality, plan effective met, patient¶ s
grimace right hand, to abdomen will severity, and treatment. pain on the
(+) guarding increase constipation decrease from precipitating factors. abdomen
behaviour upon irritation to the because of 5/10 to 0/10. decreased to
painful sites airway due to limited OFI of c '   &

$ use of non 0/10.
(+)fatigue limit OFI, 500mL/day.
(
$ Patient¶s $ Teach the use of invasive pain

(+)weakness possible Throat pain throat pain will non pharmacologic relief measures
(
$
Goal
(+)dizziness constipation may be due decrease from techniques (e.g., can increase the partially met.
(+) poor due to limited to frequent 3/10 to 0/10. relaxation, release of Patient¶s
capillary refill 3 OFI irritation due guided imagery, endorphins and throat pain
sec. to increased music therapy, enhance the reduced to
(+) loss of secretions. distraction, and therapeutic effect 1/10.
appetite massage) of pain relief
(+) malaise medications.
(-) dry skin
(-)hematoma )
This is due to To
)
$
Patient¶s c '   &
$
Limitation of )
$
Goal
(-) rashes Fluid volume Na and water facilitate edema will $ Maintained on sodium and water partially met.
(-) clubbing of excess related retention and the decrease from prescribed diet, low will help in Patient¶s
nails to impaired reabsorption mainte- grade 3+ to sodium low fat and preventing more edema
(-) pruritus venous return in the kidney nance of grade 2+. limit Oral Fluid fluids to enter the remained on
(+) pinkish secondary to due to RAAS fluid and intake to 500 system therefore Grade 3+.
conjunctiva increased stimulation. electrolyte ML/day. preventing
(+)dysphagia peripheral balance edema.
(+) aphonia resistance and
(-) neck decreased
stiffness efficiency of
(-) enlarge or valves.
tender lymph
nodes
(+) distention of
neck veins
(+)productive
cough with
presence of
yellowish,
about 1mL per *
Decreased This is due to To
*,+
$
c '   &
$
Exercising will *,+
$
Goal
expectoration cardiac output failure of the facilitate Patient¶s BP $ Performed passive help the blood partially met.
of secretions related to heart to the will increase ROM as tolerated by circulation and Patient¶s Bp
(+) DOB, decreased pump mainte- from 90/60 to the patient. promote return remained
tachypnea 30 stroke volume enough nance of a 100-110/70- good circulation 90/60mmHg.
cpm to to Left sided blood in the supply of 80mmHg. and transport of
(+) use of heart failure. systemic oxygen to nutrients from the
accessory +
circulation. all body blood to cells.
muscles when Activity cells
breathing Intolerance
(+) Anorexia related to
(-) diarrhea compromised
(-) nausea oxygen
(-) vomiting transport
(-) constipation system
(-) oliguria secondary to
(+) weak Congestive
thread pulse heart failure.
(+) testicular
edema
(+) numbness
on both foot -
This is due to To
-
$
Patient c '   &
-
$
Goal
(-) joint swelling Insomnia Paroxysmal promote will be able to $ Promoted quiet $
Promoting quiet met. Patient
(+) bipedal, related to Nocturnal good sleep at least environment and environment will was able to
right hand frequent Dyspnea. hygiene 3-5 hours. closed the curtains. help patient to sleep 4 hours.
pitting edema awakenings and sleep.
grade 3+ secondary to physical
circulatory and comfort.
respiratory
disorders.
.
This is due to To
.
$Patient will
%&

.
$
Goal
Risk for the decrease promote not develop $
Assessed $ Establishes met. Patient
infection cardiac safety any signs and skin. Noted color, comparative did not further
related output, through symptoms of turgor, and baseline providing manifest any
compromised meaning prevention infection. sensation. opportunity s/sx of
host defences WBC cannot of Described and for infection
secondary to travel fast to accidents, measured wounds timely
respiratory fight the injury, or and observed intervention.
disorders invading other changes.
micro- trauma
organisms. and c '   &

through $ Demonstrated
the good skin hygiene. $
Maintaining
prevention clean, dry skin
of the provides a barrier
spread of to infection.
infection Patting skin dry
instead of rubbing
reduces risk of
dermal trauma to
fragile skin.