Nursing Diagnosis:

Ineffective airway clearance may be related to copious tracheobronchial

secretions and bronchospasm as manifested by:
a. Subjective: “Nabudlayan ko mag ginhawa kung kis-a gani gasakit akon
dughan mag ubo.”
b. Respiratory rate of 25 breaths/minute, labored, shallow, rapid,
c. Persistent productive cough noted and expectorates to a copious, yellow
to greenish, blood streaked sputum approximately 2-3 cc per
expectoration
d. Dyspnea after prolonged conversation
e. Decreased tactile fremitus at lower lobe of the left lung.
f. Asymmetrical chest expansion with left chest slightly higher upon
inspiration
g. Dullness heard upon percussion of the posterior left lung
h. Crackles heard over the right lung and pleural friction rub on the left lung
i. Pneumonia, left lung with right consolidation as shown in the X-ray results
last September 1, 2005.

Definition:

Inability to clear secretions or obstructions from the respiratory tract to

maintain a clear airway

Goals of Care:

a. Within 8 hours of nursing and medical interventions, patient will be able

to maintain a patent airway.
b. Within 30 minutes to 1 hour of medical and nursing interventions, patient
will be able to clear airways through effective expectoration of secretion.
c. Within 1 hour of nursing interventions, patient will effectively perform and
participate in deep breathing exercises.
d. Within 1-2 hours of medical and nursing intervention, patient will
verbalize relief of dyspnea as exhibited by ability to withstand prolonged
conversation.
e. Within 8 hours of medical and nursing intervention, patient will manifests
a decrease in abnormal breath sounds.

INTERVENTIONS RATIONALE
NURSING
Assessment/Diagnostic:

1. Monitor respiratory rate, Abnormalities may indicate difficulty

rhythm, depth, and chest of breathing and respiratory distress
movements.

2. Assess ability to expectorate To determine if patient can

secretions effectively and expectorate secretion effectively and
assess the characteristics, to note for the severity of infection
quantity, color, consistency,
and odor of sputum.

3. Auscultate lungs for crackles, Determines the adequacy of gas

pleural friction rub, wheezes, exchange and extent of airways
and decreased airflow. obstructed with secretions

4. Routinely check the patient’s To maintain position that promotes

position. maximum lung expansion

1
Treatment/Therapeutic:

1. Assist patient with coughing Coughing removes secretions to

and deep breathing exercises prevent atelectasis. Deep breathing
at least 10 times every hour exercises facilitate maximum
while awake. expansion of the lungs or the smaller
airways.

2. Position patient in semi to high Secretions move by gravity as

fowler’s position changes. Elevating head of
bed moves abdominal contents away
from diaphragm to enhance
diaphragmatic contraction and
relieves dyspnea.

3. Perform chest physiotherapy Applying percussion and vibration to

such as percussion and chest loosens secretions so that it
vibration. can be expectorated.

4. Assist patient with oral hygiene Removes taste of secretions and

every after Pulmo-aid prevents irritation of the oral mucosa
inhalation or as needed after Pulmo-aid inhalation.

5. Provide fluids (water) To liquefy secretion for easy

expectoration

6. Perform hand washing before To prevent spread of infection

and after contact with patient
or care.

7. Provide sputum receptacle and To prevent contamination and for

tissue by bedside. proper disposal of infectious materials

To lessen oxygen consumption, thus

8. Limit verbal interaction or preventing occurrence of dyspnea.
discussion to
important/significant topics or
issues.
To lessen pain perceive every time
9. Encourage rest during patient experiences cough and
exacerbation of cough or dyspnea.
dyspnea.

Health Teachings:
Liquefies secretions so that they are
1. Encourage patient to increase easier to expectorate
fluid intake to 1.5 to 2 liters
per day.
To prevent contamination, cross
2. Instruct and demonstrate infection and maintain cleanliness
proper hand washing.
Provide information, aid in lung
3. Teach patient the importance expansion, airway clearance and
of deep breathing and easily expectorate secretions
coughing exercises and
demonstrate the proper way to
perform.

2
 Secretions are moved by gravity as
4. Encourage patient to ambulate position changes and during
when tolerated and change ambulation.
position at least every 2 hours.
To lessen discomfort and pain
5. Teach patient to splint chest
when coughing.
To prevent spread of infection
6. Instruct patient to cover mouth
when coughing.
To prevent cross contamination
7. Teach patient and family between patient and significant
members/visitors good hand others
washing technique.
To provide adequate rest to patient
8. Instruct family members, and prevent the occurrence of
significant others and visitors dyspneic episodes and chest pain
to limit prolonged conversation
or discussion with patient.

COLLABORATIVE
Assessment/ Diagnostics:
Shows extent and location of lung
1. Monitor chest x-ray results. involvement

Identifies microorganisms present so

2. Monitor sputum gram stain and that appropriate anti-infective agents
culture and sensitivity reports. can be prescribed

Treatments/Therapeutic:
Aids in reduction of bronchospasms
1. Administer Pulmo-Aide and dilation of bronchial smooth
Inhalation with Salbutamol 1 muscles
nebule every 6 hours as
ordered.
Decrease mucus viscosity by breaking
2. Administer acetylcysteine or altering chemical bonds or
(Fluimucil) 600 mg/tab 1 tablet glycoprotein complexes.
dissolved in ½ glass water as
ordered.
To prevent drying of secretions and
3. Provide humidified oxygen as lung ventilation
needed.

Health Teachings:
To provide patient and significant
1. Inform patient and significant others information of what to expect
others of the possible side after taking the medications
effects of medications such as:
a. Salbutamol- headache ,
tremors, tachycardia
and palpitations
b. Fluimucil-
nausea/vomiting,
urticaria, bronchospasm

3
Evaluation:

After 30 minutes of medical and nursing intervention,

Patient was able to effectively expectorate secretion (copious, yellow to
greenish, blood streaked sputum approximately 2-3cc per expectoration).
Patient verbalized relieved of dyspnea even after conversation.
Patient was able to perform splinting activity, covers mouth when coughing,
dispose used tissue appropriately in a receptacle.

After 8 hours of medical and nursing intervention,

Patient was able to maintain a patent airway.
Patient, family members and visitors demonstrate proper hand washing
techniques.
Patient demonstrates effective deep breathing and coughing technique

4
Nursing Diagnosis:

Disturbed Sleeping Pattern maybe related to persistent coughing at night as

evidenced by:
a. Subjective cues: “Kulang gid akon tulog kay sige-sige akon ubo kung
gab-i siguro mga tatlo lang asta lima kaoras akon tulog, kis-a gani
gasakit na akon dughan ka-ubo.”

Definition:

Time-limited disruption of sleep (natural, periodic suspension of

consciousness) amount and quality.

Goals of Care:

Within 8 hours of nursing and medical interventions, the patient will sleep for
1-2 hours after lunch.

Within 24-48 hours of medical and nursing interventions, the patient will be
able to:
a. Report improvement in sleep, 6-8 hours at night
b. Report increase in sense in well-being and feeling rested during the day
c. Identify individually the appropriate interventions to promote sleep at
night
d. Participate actively in activities planned for him during the day.

INTERVENTIONS RATIONALE
NURSING
Assessment/Diagnostic:

1. Assess for factors that To control factors that may contribute

contribute to sleep pattern to inadequate hours of sleep
disturbances other than
presence of persistent cough;
routine nursing care; noise;
pain/ discomfort.
To determine usual sleep pattern and
2. Observe and obtain feedback provide comparative data
from patient or significant
others regarding usual
bedtime, rituals, routines,
number of hours of sleep, time
of arising and environmental
needs.
To plan and evaluate appropriate
3. Monitor hours of continuous interventions, which patient could
sleep at night or during the tolerate and determine usual sleep
day and time of arising. pattern to provide comparative
baseline

To plan schedule of activities to

4. Observe for signs of fatigue, provide rest periods for the patient
restlessness, irritability, and
poor compliance to activities
planned for patient such as
vital signs taking, treatments,
and administration of
medications.
To provide an environment conducive

5
 5. Note environmental facilities for rest
that may affect the sleeping
pattern of the patient such as
air conditioning unit, electric
fans, lights, and curtains.
To know what the patient really
6. Listen to patient’s report of feels toward the problem
sleep quality.

Treatment/Therapeutic:
A quiet environment promotes sleep
1. Provide a quiet environment and relaxation
such as closing the door and
minimize getting in and out of
the room.
To promote sleep and relaxation
2. Provide a dim environment for
sleep time.
To promote sleep and relaxation
3. Provide comfort measures such
as backrub, washing of hands
and face, bathing, oral
hygiene, cleaning and fixing
linens in preparations for
sleep.
To promote relaxation and comfort
4. Let patient assume position of during sleep, to promote circulation,
comfort without compromising adequate tissue perfusion
body alignment.

That patient will be able to perform

5. Schedule patient’s program of activities at his optimum level. Limit
activities and routine nursing fatigue and exhaustion in activities of
care with rest periods daily living performance

Provide an environment conducive for

6. Adjust air condition sleep.
thermostat to keep room cool
or provide electric fan for
patient as needed.
Provide a comfortable sleep for
7. Provide extra blanket by patient.
bedside during nighttime sleep
in case patient feels cold or
chilly, or change after
perspiring or diaphoretic
episode. (linens included)
To minimize disturbances such as
8. Close door if patient prefers noise and visitors from going in and
during rest or sleep time. out of the room

To allow only those visits that are

9. Post a sign on closed door, if
patient is resting or asleep.
- Limit or screen visitors.
- Knock softly on door
before opening and
entering room.
- Post a sign that says:
very important so that patient will
have longer time for resting. To
screen visitors and provide health
teachings such as washing of hands
before and after

6
 “Check with nurse on
the station before
entering room”

Health Teachings:
Aid in stress control or release of
1. Encourage and stress the energy because exercise in late
importance of participation in afternoon or in the evening may
regular exercise program stimulate rather than relax the client
during the day, such as deep and may even interfere with sleep
breathing and coughing
exercises and other active and
passive range of motion
exercises as tolerated.
For patient to prevent intake of
2. Inform patient that foods and caffeine rich foods and drinks that
drinks high in caffeine such as could interfere with sleeping pattern
tea, coffee, cola drinks, and
chocolates may interfere with
sleep.
To the regain the energy from lack of
3. Encourage to nap after lunch. sleep during the night

Being energized before bedtime

4. Instruct patient not to engage would bring about difficulty of sleep
in strenuous activities such as
weight bearing before sleeping
time.
For comfort measures
5. Instruct patient to have extra
clothing by bedside or shirts to
change when perspiring or
wet.

COLLABORATIVE:
Assessment:
To inform physician of side effects
1. Note for side effects of present on the patient that could
medications (Fluimuci)l such as alter sleep.
nausea/vomiting, urticaria an
bronchospasm, that could
cause sleep disturbance.

Treatment:
For physician to do appropriate
1. Report interventions regarding patient’s
persistence of sleeplessness continued inability to sleep
after performing applicable
independent interventions

Health Teachings:
To inform physician of the sleep
1. Encourage patient to verbalize disturbance caused by the
side effects of medications medications
experienced that alter sleep
such as exacerbation of cough
at night may be due to
Fluimucil, a mucolytic, which is
taken at bedtime.

7
 To encourage patient to take
2. Stress the importance of medications strictly that helps lessen
compliance to medications and symptoms of disease that alter sleep
treatments

Caffeine is a stimulant
3. Explain the importance of
compliance of avoiding
beverages with caffeine. Reading and listening to music could
promote sleepiness
4. Encourage reading and music
therapy before afternoon nap
or nighttime sleep.

Evaluation:

After 24-48 hours of nursing and medical interventions, patient verbalized

that, he had approximately 6-8 hours of sleep after the relief of symptoms of the
disease such as cough and chest pain.

He stated that he had decreased physical exhaustion during the day.

The patient and significant others expressed performance of sponge bathing

and turning off lights before sleep.

8
Nursing Diagnosis:

Chronic pain may be related to persistent coughing as manifested by:

a. Subjective: “Nabudlayan ko mag ginhawa kung kis-a gain gasakit akon
dughan mag ubo.”
b. Verbalized chest pain felt rated as 6 in a scale of 0-10 (0 for no pain and 10
as to excruciating pain) gradually decreasing after coughing lasting 2 to 3
minutes, aggravated by return of coughing and prolonged conversation
c. Facial grimace and muscle guarding as claimed

Acute pain as manifested by:

a. Burning pain on the IV site rated as 3 in the scale of 0-10,
aggravated by moving, alleviated by immobilization.
b. Grade 1, non-pitting edema noted at IV site.

Definition:
Unpleasant sensory and emotional experience arising from actual or potential
tissue damage of described in terms of such damage; slow onset of any intensity
from mild to severe, constant or recurring without an anticipated or predictable end
and a duration of more than six months, or duration of the disease.

Goals of Care:
a. Within 1-2 hours of medical and nursing interventions, patient will be able to
report decrease of pain when coughing from a scale of 6 to a scale of 4 in
McGill’s Scale of Pain, 0 as to no pain and 10 as to excruciating pain.
b. Within 1-2 hours of medical and nursing interventions, patient will
demonstrate use of relaxation skills and diversional activities such as chest
splinting, deep breathing exercises, reading and listening to the radio or
watching television.
c. Within 4 hours of nursing and medical interventions, patient will perform
routine activities of daily living such as transferring, ambulating, bathing,
grooming and hygiene, toileting with minimal set-up or 1 person assist.
d. Within 1-2 of nursing and medical interventions, patient will verbalize relief
of pain in the IV site.
e. Within 1-2 hours of nursing and medical interventions, patient will manifest
decrease size of edema on the IV site.

INTERVENTIONS RATIONALE
NURSING:
Assessment/Diagnostic:

1. Determine pain characteristics; To know the severity of pain felt thus

investigate changes in the be able to give appropriate nursing
character, location, and interventions
intensity of pain using the
McGill’s scale.

2. Continually monitor vital signs Any alterations in the vital signs may
every 4 hours. indicate presence of pain.

3. Identify aggravating factors for To be able to control these factors

pain. and to know what kind of intervention
will be given

4. Assess for characteristics of To know the severity of pain felt thus

pain on the IV site. be able to give appropriate
interventions

9
 5. Note for the presence of To know if the IV line is patent
edema on IV site

Treatment/Therapeutic:

1. Provide comfort measures such Non-pharmacological measures help

as backrubs, relaxation, and alleviate pain. It refocuses attention,
deep breathing exercises. promotes relaxation, and enhances
sense of control, which may reduce
pharmacological dependency.

2. Assist patient to assume To promote maximum lung expansion

position of comfort such as and comfort that lessens pain.
elevation of the head of the
bed, sit on edge of bed, and
assume orthopneic position.

3. Provide diversional activities Helps lessen concentration on pain

appropriate for age and experience and refocus
condition such listening to
radio, watching TV, reading

4. Provide set-up or assist with To minimize exertion of much effort

routine activities of daily living in doing such activities of daily living
such as transfer from bed to so as to lessen pain perception
chair, ambulate, toileting,
hygiene, bathing, grooming.

5. Keep patient’s back dry. Pat To promote comfort

dry and change shirt as
needed.

6. Provide warm compress on To alleviate pain perceived.

knee every time there is pain

7. Elevate left forearm and apply To reduce edema, facilitating venous

warm compress. return

Health Teachings:

1. Encourage patient to report So that proper interventions can be

pain. done

2. Instruct and assist patient in To lessen pain and promote comfort

using pillow to splint chest
during coughing episodes.

COLLABORATIVE:
Therapeutic
Provides baseline data, which can be
1. Refer accordingly for use for treatment regimen.
persistence of pain if not
relieved by non-
pharmacological measures.

10
Evaluation:

At the end of 2 hours of medical and nursing interventions, patient verbalized

a decrease in pain from a rating of 5 to 3 with splinting upon coughing.

He shows a relaxed manner, resting, sleeping, and engaging in activities

such as feeding himself, performing oral care, and ambulating with one-person
assist.

Edema on IV site not noted.

Patient engages in activities such as reading, listening to music on the radio

and watching television.

Vital signs are within patient’s normal range.

11
Nursing Diagnosis

Altered nutrition: less than body requirements may be related to discomfort

associated with coughing and dyspnea as manifested by:
a. Subjective cues: “Nagniwang gid ko ya. Halin sa 49.6 kilos sang sine
lang nga Agosto 29, 45 kilos na lang akon timbang subong.”
b. Subjective cues: ”Indi gid manamit ang sud-an sa hospital.”
c. Subjective: “Di ko gawa ka panimaho kung lain matyag ko….”
d. Subjective: “Indi mayo ang panabor ko sa pagkaon kay gina ubo ako…”
e. Consume 45% of the meal served in the hospital.
f. With poor smelling acuity on both nares upon testing with the use
orange peelings and bath soap
g. With decreased ability to differentiate, taste of sugar and coffee upon
testing.

Definition:

Intake of nutrients is insufficient to meet metabolic needs.

Goals of Care:

a. Within 2 hours of medical and nursing intervention, patient will verbalize

food choices or preferences.
b. Within 2-3 days of medical and nursing interventions, patient will manifest
increase in appetite by consuming approximately 60-75% of meals
served.
c. Within a week of nursing interventions, patient will be able to gain at least
2 kilos approximately.

Inadequate tissue perfusion maybe related to decrease in hemoglobin and

hematocrit count as evidenced by:

a. slightly pale conjunctiva, palm of the hands and nailbeds

b. poor capillary refill of 3 seconds upon blanching test
c. hemoglobin count of 11.6 g/dL (Sept. 1, 2005)
d. hematocrit count of 34.7% (Sept. 1,2005)

Definition:

Decrease in oxygen resulting in the failure to nourish the tissues at the

capillary level.

Goals of Care:

1. Within 8 hours of nursing intervention/treatment, patient will exhibit

adequate perfusion as evidenced by:
a. Blood pressure within patient’s normal range 110/70-120/80 mmHg.
b. Heart rate strong and regular <100 beats per minute
c. No significant change in mental status: alert and oriented to time,
person, place and events.
2. Within 8 hours of nursing intervention/treatment interventions, patient will
exhibit adequate peripheral pulses amplitude of 2+ on a 0-4+ scale.

12
 INTERVENTIONS
NURSING
Assessment/Diagnostic
1. Assess patient’s food choices or
preferences.
2. Determine other factors, which
contribute to patient’s poor
appetite such as coughing,
expectoration, incomplete set
of teeth and presence of
dentures.
3. Assess hydration status:
a. check skin turgor
b. check fluid intake
4. Auscultate for bowel sounds.
5. Assess patient’s last bowel
movement.
6. Assess patient’s weight
continually.
7. Assess peripheral perfusion
status for skin color, skin
temperature, quality of pulses
and capillary refill.
8. Assess patient’s level of
consciousness, orientation to
time, person, place, and
events.
9. Continuously monitor vital
signs especially blood pressure
every 4 hours; assess for
dizziness.
10. Observe for restlessness,
confusion, change in level of
consciousness or mental status.
11. Watch out for presence of chest
pain and irregular heart rate.
RATIONALE
To know if patient’s food preference
is nutritional or not and to find out
what foods will stimulate his appetite
To control factors that could alter or
decrease desire to eat.
To determine if patient is
dehydrated.
Document GI peristalsis needed for
digestion.
Unable to defecate decreases
appetite. (one of the side effects that
patient may experience while taking
Propan with Iron is constipation)
This will serve as a baseline data and
for evaluation of nutritional status in
relation to food intake.
Cool skin temperature, pallor,
decreased motor or sensory function
and venous engorgement
(prominence) in lower extremities
are signs of inadequate peripheral
perfusion.
Alteration in the level of
consciousness may be due to
decreased oxygenation in the brain
To obtain baseline data and assess
the status of the patient; Dizziness
might indicate orthostatic
hypotension.
These factors indicate inadequate
oxygenation in the brain
This may indicate inadequate oxygen
supply to major organs in the body
such as the heart
13
 12. Monitor CBC results
(especially Hgb and Hct levels).
Treatment/Therapeutic
1. Provide small frequent meals
foods that are appealing to the
patient.
2. Provide or assist with oral
hygiene after Pulmo-Aide
Inhalation.
3. Maintain a clean environment.
Remove noxious stimuli such as
bedpan, urinal, and trash can.
Dispose used tissues in sputum
receptacle before mealtime.
4. Assist with proper hand
washing before and after
mealtime.
5. Serve food according to diet
ordered for the patient. (Diet
As Tolerated)
6. Assist with oral hygiene and
denture care as needed.
7. Acknowledge every time
patient is able to consume
food.
8. Instruct patient and family to
keep skin moisturized with
lotion.
9. If hypotension is present, stop
activity, assist patient to sit or
assist back to bed, place
patient in supine position.
10. If hypotension is present:
instruct to change position
slowly in bed, provide
assistance with routine ADL
care as in positioning, transfer,
toileting, grooming and
hygiene; keep side rails up for
safety, bed mobility, positioning
and transfers.
An alteration in this laboratory
results may indicate decreased
amount of circulating red blood cells
that are responsible for supplying
oxygen to different parts of the
body.
Stimulate appetite but requires less
energy thereby reducing oxygen
requirement.
Stimulates good appetite; Prevents
the risk for fungal infection.
Unclean environment or offensive
odors decrease patient’s appetite to
eat.
Reduce microorganisms present in
the hands of the patient
To meet the specific metabolic need
of the patient.
Promote hygiene and develop
independence; Removes sputum and
food particles in the mouth and
dentures.
To motivate patient to eat more
Patient has dry skin so to moisturize
the skin.
To relieve hypotension
To prevent occurrence of orthostatic
hypotension
14
Health Teachings:

1. Instruct patient to get out of To facilitate passage of food and

bed and sit in chair during easy digestion; avoid aspiration
mealtime.

2. Instruct patient to perform oral For proper hygiene and to diminish

care such as brushing the floor the bad taste of phlegm; remove
of the tongue and cleaning of food particles
dentures before and after
meals.

3. Inform patient that eating a Increase patient’s awareness of

balance diet each day is proper eating habits.
important in maintaining the
immune system.

4. Encourage patient to consume To increase patient’s food intake

approximately 60-75% of
meals served.

5. Advise patient to take food and

drinks rich in:

• Vitamin C such as citrus Vitamin C – rich foods increase the

fruits or drinks an orange absorption of iron and enhance
juice. immunity.

• Folic acid such as green It aids in protein metabolism

leafy vegetables (iron
rich foods like liver and
other organ meats)

• Protein rich foods such They repair and maintain body

as meat, milk and fish tissues

• Vitamin B6 such as liver Isoniazid decreases pyridoxine in the

and organ meats stomach

• Carbohydrates such as They are the body’s major source of

rice, corn and bread energy and utilize other nutrients

• Vitamin A such as cheese To improve eyesight

and carrots

• High fiber foods such as To prevent constipation brought

ripe papaya and green about by medications
leafy vegetables

6. Instruct patient to take To avoid GI irritation

medications with food

7. Instruct patient to avoid To avoid accidents due to drowsiness

activities that requires mental effect of medications
alertness

15
COLLABORATIVE:
Assessment:
Evaluate fluid and electrolyte
1. Evaluate Chemistry report for imbalance especially Sodium
electrolyte levels in the blood.
Know that Propan with Iron causes
2. Instruct on the side effects of black-colored stool and constipation.
Propan with Iron

Treatments/Therapeutic:
1. Give vitamins as ordered:
a. Centrum 1 tablet once a
day
2. Provide supplemental
intravenous fluids as ordered.
3. Administer Propan with Iron 1
capsule once a day at 8 pm
To serve as a multi-vitamin
supplement
To avoid dehydration due to
insensible loss of fluids
Stimulates appetite and serves as an
iron replacement; aids in the
production of red blood cells

Health Teachings:
To stimulate appetite
1. Encourage wife to bring favorite
foods of the patient such as
“Tinolang manok”
To provide information and
2. Inform patient and significant awareness of the possible effects of
others of the side effects of medications
medications and to watch out
and report for adverse
reactions:
a. Centum- GI upset and
irritation
b. Propan- mild drowsiness
and GI discomfort

Evaluation:

After 1 hours of nursing and medical intervention, patient was able to

verbalize food choices and preferences.

After 3 days of nursing and medical intervention, patient is able to consume

more than or equal to 75% of the meals served in the hospital.

Patient increased his fluid intake to 2 liters per day. He was able to consume
foods from home and perform good oral hygiene and denture care.

After 2 hours of nursing and medical interventions, patient was able to

verbalize food choices, preferences, and sits up in chair for meals.

At the end of 4 hours of nursing intervention, patient exhibited strong,

palpable peripheral pulses +2, strong, regular heart rate, synchronous with left
radial pulse rate of 82 beats per minute.

16
 No significant changes in level of consciousness or mental status, patient is
alert, oriented to time, place, persons and events, with capillary refill of 2 seconds,
skin is warm and moist to touch.

At the end of 2 days of nursing interventions/treatment, patient exhibited

pinkish bilateral conjunctiva, palms of hands and nail beds.

17
NURSING DIAGNOSIS:

Social Isolation may be related to altered state of wellness secondary to

persistence of uncontrolled cough as evidenced by:

a. Subjective: “Nahuya na ko mag atubang sa mga taw okay gaubo ako

permi.”

Definition:

Aloneness experienced by the individual and perceived as imposed by

disease condition and as a negative or threatened state.

Goals of Care:

Within 1 hour of medical and nursing interventions, the patient will be able to
interact verbally with nurses, medical staff, or other persons, significant others,
visitors with no breathing difficulty (coughing, dyspnea) or exhaustion.
Within 1-2 hours of medical and nursing interventions, the patient will be
able to express increased in self-worth such as smiling and interaction.

INTERVENTIONS RATIONALE
NURSING
Assessment/Diagnostic

1. Assess patient’s feelings about Serve as a basis for determining

self, disease condition, sense appropriate interventions to be given.
of ability to control situation,
sense of hope and coping
skills.

2. Assess factors that may To control factors that may increase

contribute to isolation such as patient’s feelings of being isolated
patient’s health status from others.
(persistent cough).

3. Identify support systems When patient has assistance from

available to patient such as significant others, feelings of shyness
presence significant others. are diminished

Treatment/ Therapeutic

1. Talk to patient about topics To promote verbal interaction,

that may interest him. diminishing feeling of shyness

2. Provide positive reinforcement Encourage continuation of efforts

when client initiates
conversation with others
(visitors, health team).

3. Promote participation in special To promote socialization skills and

interest activities such as interpersonal contact
having conversations with
health team, visitors and
significant others.

4. Continue to screen or limit To afford the patient rest, limit the

visitors of patient. risk of spread of infection.

18
 5. Schedule rest periods in
between social or routine
health related activities (such
as vital signs taking, bathing,
and meals).
To allow patient to rest and gain
enough strength to accomplish other
health related or social tasks

Health Teachings

1. Encourage patient to ambulate To meet and interact with different

out of room in hallway with people and health staff or team
assistance or supervision.

2. Encourage patient and Helps reestablish a feeling of

significant others to converse participation in a social relationship.
and interact with each other.

3. Encourage family members to To reduce sense of isolation and

use touch when interacting promote healthy socialization
with patient.

4. Instruct to choose and pace So as not to feel exhausted or trigger

conversations or verbal cough episodes
interactions appropriately.

5. Instruct to cover mouth when To prevent cross infection

coughing.

6. Instruct patient to bring with To prevent cross infection

him disposable tissue paper
and dispose properly after use
in sputum receptacle.

7. Encourage family or significant To develop self-esteem and increase

others to provide praise for self-worth
attempted or accomplished
tasks.

Evaluation:

After 2 hours of nursing and medical interventions, patient was able to:
Ambulate with 1 person assist out of room.
Interacted for 10 minutes with another patient and the health team,
conversed with family and significant others.
Family members especially wife uses touch therapy when verbally interacting
with patient.
Patient smiles, maintains eyes contact when talking about topics of interest.

19
Nursing Diagnosis:

Knowledge deficit regarding disease condition, treatment needs, and

discharge needs may be related to lack of information about the disease as
evidenced by:

a. Subjective cues:” Gapacheck up ko pero wala ko kabalo kung anu

sakit ko kay wala ya man ginhambal sa akon…basta ginaresitahan lang
ko…anong pulmonya day haw?”

Definition:

Absence of cognitive information related to specific topics (mentioned above)

Goals of Care:

a. Within 2 hours of medical and nursing interventions, patient will be

able to explain the disease condition, treatment, and discharge needs.
b. Within 2 hours of medical and nursing interventions, patient will be
able to enumerate the importance of compliance to drug regimen,
medical and nursing treatments and health teachings.

INTERVENTIONS RATIONALE
NURSING:
Assessment/Diagnostic:

1. Determine impediments or To serve as basis for choosing

obstacles to learning such as
low educational attainment,
hearing problem and use of
adaptive device such as
eyeglasses.
appropriate topics, terminologies and
approach in educating the patient
about the disease

2. Assess the patient if he can To establish good communication

hear and understand what is
being spoken.

3. Ask patient some questions To determine what information about

about Pneumonia and the disease still needs to be
Tuberculosis. discussed

4. Identify signs/symptoms Prompt evaluation and timely

requiring notification of intervention may prevent or minimize
healthcare provider such as complications
increasing dyspnea, chest pain,
prolonged fatigue, weight loss,
fever and chills, continuous
productive cough and changes
in mentation.

5. Assess patient’s interest and To identify a need to reschedule

attention span for interaction activity and simplify explanation as
and education. needed.

Treatment/Therapeutic:

1. Organize content about For the patient to easily understand

Pneumonia. what is being explained by the nurse
and to avoid missing important

20

2. Choose appropriate time and
condition of the patient in
providing information related to
Pneumonia.
3. Establish rapport by introducing
self, maintaining eye contact,
smiling, and approaching
patient in a calm manner;
explain to patient and the
purpose of visit or interaction.
4. Speak directly facing the
patient. Use well modulated
tone of voice.
5. Give information on patient’s
right ear.
6. Use terms or statement that is
simple for patient to
understand according to
intellectual or educational level.
7. Ask questions after giving
health teachings and
instructions.
8. Provide information about the
importance of medications,
treatments, and health
teachings in written and verbal
form.
9. Ask patient to repeat or clarify
information provided, as
needed.
Health Teachings:
1. Discuss in simple terms the
normal functioning of the lungs,
how it is related to Pneumonia
and its contributing factors.
2. Explain to the patient and the
significant others the nature of
the disease such as its
communicability, and its
complications
3. Stress importance of continuing
deep breathing and effective
details
Patient could listen effectively on the
time and condition he is most
comfortable
To establish good communication
between the nurse and patient; to
provide basic knowledge of the
purpose of the visitation and to
deliver information clearly
To get the patient’s attention and
that he can understand better what
you are saying
The right ear is patient’s good ear.
Give information here for better
acuity
Patient has a low educational
attainment so its essential to use
terms or statement within his level of
comprehension.
To evaluate whether the patient
understood what was asked
For the patient to understand the
importance of medications,
treatments and health teachings in
relation to the disease
For patient to understand better the
information.
It is easier to understand what is
abnormal if the normal anatomy and
physiology of the lungs is discussed
first; to provide information and
awareness to the patient
To let them know what to expect
during the disease period, the
necessary interventions and to avoid
the spread of the disease.
During the initial 6-8 weeks after
discharge, patient is at great risk for
21
 coughing exercises.
4. Outline steps to enhance
general health and well-being
such as balanced rest and
activity, well-balanced diet,
avoidance of crowds during
cold/flu season and persons
with respiratory infections.
6. Encourage patient and family
members to ask questions.
7. Encourage patient and
significant others to ask
questions about Pneumonia.
7. Instruct patient to wear
eyeglasses during interaction
or when reading materials are
provided.
COLLABORATIVE:
Health Teachings:
1. Identify available resources
such as health clinics and
health centers or support
groups especially in their
community to validate
information post discharge.
2. Stress importance of
continuing medical follow-up
check up and obtaining
vaccinations and
immunizations.
3. Encourage the patient to seek
dietary consultation regarding
the appropriate foods for his
condition.
4. Inform the physician of lack of
knowledge on the patient’s
condition, needs, and
treatment given.
5. Emphasize the need of
continuing antibiotic therapy
for prescribed period.
6. Instruct patient to keep a list
of medications he is taking and
to keep in a place where an
assigned significant other or
recurrence of pneumonia.
To increase natural
defenses/immunity, limit exposure to
pathogens
For clarification of information
For clarification of information
To aid the patient because he has
vision problems
Patient needs accessible knowledge
especially from the rural health
center because it is where he initially
seeks assistance when he gets sick.
May prevent recurrence of
pneumonia and or related
complications
For the patient and significant others
to have thorough knowledge for what
is good and what is contraindicated
for the disease.
For appropriate physician
interventions to the disease process
Early discontinuation of antibiotics
may result in failure to completely
resolve the infection and may lead to
an increase in resistance of
microorganisms to the drug.
So that in case of questions or
emergency significant others and
family would readily have a guide as
to what his medications are all about.
22
 family members have access in
case of questions and
emergencies.

7. Advise patient and significant To provide immediate interventions

others to have a hearing on the patient’s hearing loss
consultation with a doctor, if
needed.

8. Teach patient and significant Provide knowledge to patient in

others on how and when to relation to his further recovery.
take the different medications
and treatment, what kind of
activities or exercises to be
done, how to maximize the
available community
resources, when to visit the
clinic for check-up, the proper
diet to be followed, and uplift
spirituality and awareness of
culture upon discharge.

Evaluation:

After 2 hours of nursing and medical interventions, patient was able to

differentiate Tuberculosis from Pneumonia. Furthermore, he also learned that he
was admitted due to Pneumonia and verbalized understanding and compliance with
the medications, treatments, and healthy teachings, such as performance of
breathing and coughing exercises, use of available community resources, and follow
up medical consultations and care.

Patient hears and understands questions and instructions clearly with his
right ear. He uses eyeglasses when reading printed materials provided.

Discharged plans, reviewed, clarified and understood by patient.

23
NURSING DIAGNOSIS

Activity Intolerance may be related to exhaustion associated with interruption

in usual sleep pattern due to discomfort, persistent coughing, and dyspnea as
manifested by:
a. Subjective: “Kulang gid akon tulog kay sige-sige akon ubo kung
gab-i siguro mga tatlo lang asta lima ka oras akon tulog, kis-a gain gasakit
na akon dughan ka-ubo.”
b. Subjective: “Galingin ulo ko kung mag bangon kag magkadto sa
banyo….”
c. Subjective: “Gapalanakit man lang tiil ko kag tuhod kung malamig ang
klima.”
d. Minimal aching pain felt on both ankles and knees rated as 3 in a scale
of 0-10
e. Requires one-person assistance with ambulation
f. Can only perform limited range of motion on both lower extremities

Definition:

Insufficient physiological energy to endure or complete requir\d or desired

daily activities

Goals of Care:

a. Within 8 hours of nursing and medical interventions, patient will be able

to have stable blood pressure ranging from 110/70 to 120/80 mmHg and
respiratory rate of 18-22 breaths per minute.
b. Within 4 to 5 hours of nursing and medical interventions, patient will be
able to perform and demonstrate a measurable increase in tolerance to
activity such as getting out of bed and ambulating in the room and
hallway with supervision.
c. Within 4 hours of nursing and medical interventions, patient will be
assisted with bathing, grooming and dressing.

INTERVENTIONS RATIONALE
NURSING
Assessment/Diagnostic

1. Continuously monitor vital To obtain baseline data; An alteration

signs every 4 hours. in any of the result may indicate
physiologic signs of intolerance.

2. Monitor for orthostatic blood To prevent patient accidents such as

pressure in lying, sitting, or falling caused by dizziness or loss of
standing position. balance

3. Assess patient’s balance in Determines extent of tolerance and

self-care activity performance. to facilitate the choice of
interventions and assistance or set up
needed in activities

4. Observe and evaluate response Lack of sleep may lead to fatigue.

to activity such as performance
of passive and active range of
motion exercises; bed mobility,
transfer, ambulation, hygiene,
grooming, dressing, eating,
toileting, bathing.

24
 5. Assess patient’s sleep pattern.
6. Identify factors contributing to
activity intolerance such as:
a. lack of sleep
b. lack of appropriate food
c. weight loss
d. severity of disease
condition
Treatment/Therapeutic:
1. Provide a quiet and peaceful
environment conducive for
sleep. Limit visitors during
patient’s rest periods.
2. Assist the patient to sit or back
to bed if patient complains of
dizziness with activity and
slowly assume a comfortable
position for rest and sleep.
3. Provide set-up or 1 person
assistance with transfers,
ambulation, toileting, bathing,
grooming and dressing as
need.
4. Provide comfort measures like
backrubs, slow change in
positioning, relaxation, and
breathing exercises.
5. Provide rest periods during and
after activities and routine
nursing care.
6. Keep personal items within
reach (glass, water, pitcher,
eyeglasses, personal hygiene,
and grooming materials) at
bedside.
7. Gives praise and recognition
for attempted or accomplished
task.
Health Teachings:
1. Evaluate patient’s response to
activity.
2. Explain importance of rest in
treatment plan and necessity
for balancing activities with
Reduce stress and excess
stimulation; To promote rest.
To promote rest and relaxation and
limit the effects of orthostatic
hypotension
Reduce stress and excess stimulation
and to promote rest.
To give time for rest and so that
activities will not disturb when patient
is resting; Reduce fatigue and
facilitates ventilation; Sudden
positional changes can lead to
orthostatic hypotension
To avoid fatigue and as energy saving
measures
Lessens discomfort and decrease the
risk for orthostatic hypotension
To give time for rest and reduce
fatigue
To prevent orthostatic hypotension;
for convenience and easy access
especially when patient is at bed
To motivate patient to continue doing
activities and promote independence
Establishes patient’s capabilities or
needs and facilitates choice of
intervention
Rest is maintained during acute
phase to decrease metabolic
demands thus conserving energy for
25
 rest. healing.

3. Instruct patient to avoid To prevent orthostatic hypotension

sudden position changes such
as:
a. transferring from bed to
chair
b. transferring from bed to
ambulation

4. Instruct patient to stop activity To avoid accidents such as falling

when dizzy or in pain.

5. Teach and demonstrate how to To ensure effectiveness of the

perform deep breathing
exercises by inhaling through
the nose while keeping the
mouth close and exhaling
slowly through the mouth.
exercises and so that patient will be
able to deal with his discomforts
independently

6. Instruct patient and significant Determine benefits of activities and

others to monitor response to to watch activity intolerance
activity and to recognize signs
and symptoms that indicates
alterations in activity level
such as:
a. tachycardia
b. tachypnea
c. dyspnea
d. dizziness after activity
e. poor balance

7. Give information to patient Gives awareness to patient’s current

that provides evidence of daily health status and to sustain
progress. motivation

8. Instruct patient to ambulate Avoid pooling of secretions and

and to avoid prolonged promote lung ventilation
standing and weight bearing to
knees and ankles.

COLLABORATIVE:
Treatments/Therapeutic:

1. Administer oxygen when To provide oxygenation, relieve

needed as ordered. dyspnea, and decrease work of
breathing during activities

26
Evaluation:

After 8 hours of nursing and medical interventions, patient was able to

maintain stable blood pressure ranging from 110/70 – 120/70 mmHg and
respiratory rate between 18 – 22 breaths per minute.

After 5 hours of nursing and medical interventions, patient’s activities were

spaced and scheduled with rest periods.
Patient demonstrated good balance in ambulation.
Patient required one-person assistance in bathing, grooming and dressing.
Patient can demonstrate good deep breathing techniques.
He was gradually performing activities like getting out of bed, without feeling
of dizziness and able to go to the bathroom with one-person assistance.
He had 2-3 hours of uninterrupted sleep in the afternoon and expresses relief
and feeling rested when he woke up.

27
NURSING DIAGNOSIS

Potential for spread of infection may be related to inadequate primary

respiratory defense secondary to decreased ciliary action, stasis of respiratory
secretions.

Definition:

At risk for development of further infection other than present disease.

Goals of Care:

Within 1-2 hours of medical and nursing interventions, patient will be able to
identify interventions to prevent/reduce the risk of infection such as hand washing,
proper disposal of sputum and compliance to medications.
Within 1 week of medical and nursing interventions, patient achieves timely
resolution of pneumonia.

INTERVENTIONS RATIONALE
NURSING
Assessment/Diagnostic

1. Continuously monitor vital Any alterations may indicate

signs especially temperature infection.
every 4 hours.

2. Assess for sudden changes or Parameters that may indicate

deterioration in condition such infection
as recurrence of cough,
increasing chest pain, return of
fever and changes in sputum
characteristics.

Treatment/Therapeutic

1. Change position frequently and To mobilize secretions for easy

provide good pulmonary toilet. expectoration and prevents spread of
infection.

2. Perform hand washing before Hand washing may be the simplest

and after patient care. but it is the most important key to
prevention of hospital-acquired
infection.

3. Screen visitors of patient. Individual is at increased risk for

development of infection and spread
of infection.

4. Provide or maintain a clean To minimize presence of pathogens

environment by disposing of thus decreasing risk for infection.
sputum receptacle, providing
tissue for phlegm or sputum,
disinfecting surrounding area,
bedpans, urinals, changing
water pitcher and glasses.

28
Health Teachings

1. Demonstrate and encourage Hand washing technique prevents

good hand washing technique cross infection
to patient and family members
and visitors.

2. Encourage adequate rest with To stimulate immune system

moderate exercise to recovery
tolerance.

3. Instruct patient to provide Proper disposal of infectious materials

disposable tissue for inhibits spread of infection.
expectoration.

4. Instruct patient concerning the Proper disposal of infectious materials

disposition of secretions such inhibits spread of infection.
as expectoration rather than
swallowing.

5. Instruct patient to provide Proper disposal of infectious materials

waste receptacles for phlegm inhibits spread of infection.
and sputum.

6. Encourage patient to perform Maximizes lung expansion and

deep breathing and coughing mobilization of secretions to
exercises. prevent/reduce atelectasis and
accumulation of sticky, thick
secretions

7. Increase oral fluid intake to To liquefy secretions and counteract

1.5-2 liters per day. effect of Myrin Forte which is dryness
of mouth.

8. Instruct patient not to put To prevent spread of infection

hands/fingers to face, mouth
or nose.

Collaborative:
Assessment/Diagnostic

1. Monitor effectiveness of Myrin Drugs that protects patient from

Forte. acquiring Tuberculosis

2. Monitor for side effects of To plan for appropriate interventions

Myrin Forte such as blurred and to limit the side effects of
vision, fever, malaise, dryness medications
of mouth, and flu-like
syndrome.

3. Monitor follow-up chest x-ray. To determine if patient responded to

treatment and medications.

Treatment/Therapeutic

1. Obtain sputum May be needed to identify pathogens

culture as indicated. and appropriate antimicrobials.

29
 2. Administer The maintenance for tuberculosis.
Myrin Forte as ordered.

Health Teachings

1. Instruct patient to comply with Compliance to medications decrease

medications such as Myrin risk for spread of infection and
Forte and Ceftazidime resolution of the disease condition
(Fortum). (pneumonia and TB maintenance).

Evaluation:
At the end of 1 hour of nursing and medical interventions, patient was able to
identify and perform ways to prevent infection such as hand washing, proper
disposal of sputum and compliance to medications; patient’s significant others,
family members, visitors demonstrate good hand washing technique.

At the end of 1 week of medical and nursing interventions, patient achieved

timely resolution of pneumonia.

30