VIII.

NCP Assessment Subjective: hindi ako masyado makagalaw Nursing Diagnosis Risk for Activity Intolerance r/t decrease oxyge nation Planning After 4 hours of nursing intervention the patient will participate willingly in necessary/ desired activities such as deep breathing exercises. Interventions 1. Monitor VS. 2. Assess motor function. 3. Note contributing factors to fatigue. 4. Evaluate degree of deficit. 5. Ascertain ability to stand and move about. 6. Assess emotional or psychological factors 7. Plan care with rest periods between activities 8. Increase activity/exercise gradually such as assisting the patient in doing PROM to active or full range of motions. 9. Provide adequate rest periods. 10. Assist client in doing self care needs 11. Place knees and hips in extended position Rationale 1. For baseline data. 2. To identify causative factors. 3. To identify precipitating factors. 4. To identify severity. 5. To identify necessity of assistive devices. 6. Stress and/or depression may increase the effects of illness. 7. To reduce fatigue 8. Minimizes muscle atrophy, promotes circulation, helps to prevent contractures 9. To replenish energy. 10. To promote independence and increase activity tolerance 11. Maintains functional position Evaluation Patientparticipat ed willingly in necessary/ desired activities such as deep breathing exercises.

Objective: Weak Easy Fatigability Pallor RR-26bpm P-106bpm Capillary refill 3-4seconds With thoracostomy tube

Nursing Diagnosis Subjective: Ineffective Nahihirapanakong breathing huminga as pattern r/t verbalized by the presence of patient secretions AEB productive Objective: cough and wheezing upon dyspnea inspiration and expiration dyspnea tachycardia chest tightness

Assessment

Planning After 4-5 hours of nursing intervention Patient will manifest signs of decreased respiratory effort AEB absence of dyspnea

Interventions 1. Establish rapport. 2. assess pt.s condition 3. VS monitor and record 4. Auscultate breath sounds and assess airway pattern 5. Elevate head of the bed and change position of the pt. every 2 hours. 6. Encourage deep breathing and coughing exercises. 7. Demonstrate diaphragmatic and pursed-lip breathing. 8. Encourage increase in fluid intake 9. Encourage

Rationale 1. To gain pt.s trust. 2. To obtain baseline data 3. Serve to track important changes 4. to check for the presence of adventitious breath sounds 5. To minimize difficulty in breathing 6. To maximize effort for expectoration. 7. To decrease air trapping and for efficient breathing. 8. To prevent fatigue. 9. To prevent situations that will aggravate the condition

Evaluation

Patient demonstrated pursed-lip breathing and diaphragmatic breathing.

opportunities for rest and limit physical activities. 10. Reinforce low salt, low fat diet as ordered.

10. To mobilize secretions.

Nursing Diagnosis Subjective: Ineffective Nahihirapanakong airway huminga as clearance RT verbalized by the bronchoconstri patient ction, increased Objective: mucus wheezing upon production, and inspiration and respiratory infection AEB expiration wheezing, dyspnea dyspnea, and tachycardia chest tightness cough productive cough yellowish color of phlegm

Assessment

Planning After 5-6 hours of nursing intervention the Patient will maintain/impro ve airway clearance AEB absence of signs of respiratory distress

Interventions 1. Adequately hydrate the pt. 2. Teach and encourage the use of diaphragmatic breathing and coughing exercises. 3. Instruct pt to avoid bronchial irritants such as cigarette smoke, aerosols, extremes of temperature, and fumes. 4. Teach early signs of infection that are to be reported to the clinician immediately.

Rationale 1. Systemic hydration keeps secretion moist and easier to expectorate. 2. These techniques help to improve ventilation and mobilize secretions without causing breathlessness and fatigue. 3. Bronchial irritants cause bronchoconstrictio n and increased mucus production, which then interfere with

Evaluation Patient state Ok napoangakingp aghinga, hindinaakonahih irapan

Increases sputum production Change in color of sputum Increased thickness of sputum Increased SOB, tightness of chest, or fatigue Increased coughing Fever or chills

airway clearance. 4. Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of an asthmatic person. Early recognition is crucial.

5. If indicated, perform postural drainage with percussion and vibration in the morning and at night as prescribed.

Assessment SUBJECTIVE: Medyo inuubo pa po ako As verbalized by the patient OBJECTIVE: wheezing upon expirationV/S: BP100/70mmH

Nursing Diagnosis Ineffective airway clearance related to bronchospasm and increase production of mucus secretions

Planning After 4hrs of nursing intervention, the patient will improve airway clearance and can demonstrate behaviors to improve her condition.

Interventions 1. Auscultate breath sounds. Note adventitious breath sounds.

Rationale 1. Some degree of bronchospasms presents with obstructions in airway and may/may not be manifested in adventitious breath sounds. 2. To serve as baseline data.

Evaluation After nursing intervention ,the patient can improve airway clearance and can demonstrate coughing effectively and Expectorating secretions.

2. Assess /Monitor respiratory rate. Note respiratory/expiratory ratio.

3. Elevation of the head of the bed

g T- 36 c PR- 71bpm RR- 18 bpm

3. Advised high or semifowlers position

facilitates respiratory function by use of gravity and for optimum lung expansion. 4. Precipitators of allergic type of respiratory reactions that can trigger/ exacerbate onset of acute episodes. 5. Provide patient with some means 6. These techniques help to improve ventilation and mobilize secretions without causing breathlessness and fatigue Rationale

4. Keep environmental pollution to a minimum.

5. Encourage/assist with pursed-lip 6. Teach and encourage the use of diaphragmatic breathing and coughing exercise

Assessment

Nursing Diagnosis Fatigue r/t physical exertion to maintain adequate ventilation AEB use of accessory

Planning

Interventions

Evaluation Patients will perform ADLs within clients ability and participates in desired activities

Objective:

wheezing upon inspiration and expiration

After the nursing intervention patient will be able to identify basis of fatigue and be able to cope up with

1. Establish rapport 2. Monitor and record vital signs. 3. Provide environment conducive to relief of fatigue.

1. To gain patients trust 2. For baseline data 3. Temperature and level of humidity are known to affect

 dyspnea coughing, sputum is yellow and sticky tachypnea, prolonged expiration tachycardia chest tightness

muscles to breathe

the problem. 4. 4. Assist client to identify appropriate coping behaviors. 5. 5. Encourage patient to restrict activity and rest in bed as much as possible. 6. 6. Avoid topics that irritate or upset patient. Discuss ways to respond to these feelings. 7. Discuss with the patient the need for activity 8. Alternate activity with the rest periods 8.

cyanosis

7.

exhaustion Promotes sense of control and improves selfesteem Helps counteract effect of increased metabolism Increased irritability of the CNS may cause to the patient to be easily excited, agitated and prone to emotional outburst Education may provide motivation to increase activity Prevents excessive fatigue