Documenti di Didattica
Documenti di Professioni
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A) Actual Problems
B) Potential Problems
Subjective: Ineffective airway Short Term Goal: Assess respirations: Both rapid, shallow After a week of nursing
clearance related to After 4 hours of nursing note quality, rate, breathing patterns and intervention, the patient
“Ubo ako ng ubo”as copious intervention, the patient pattern, depth, and hypoventilation affect breathing returned to
verbalized by the tracheobronchial will be able to maintain breathing effort. gas exchange. normal rate and
patient. secretions as evidence airway patency and pattern.
by cough and clear secretions readily. Monitor vital signs. With initial hypoxia and
Objective: restlessness. hypercapnia, blood
•Cough pressure, heart rate,
•Restlessness Long Term Goal: and respiratory rate all
•Pale After 8 hours of nursing rise. As the hypoxia
intervention the patient and/or hypercapnia
promote good become more severe,
Vital Sings: respiratory function. BP may drop, heart
T= 38oc rate tends to continue
P= 100 bpm to be rapid with
R= 30bpm arrhythmias, and
B/P= 110/70 mmHg respiratory failure may
ensue with the patient
unable to maintain the
rapid respiratory rate.
Subjective: Acute pain related to Short Term Goal: Bed rest with fowler or For proper breathing, After 12 hours of
“Sumasakit yung chest pain as evidence After 4 hours of nursing semi-fowler position. and reduce hypoxia. nursing interventions,
dibdib ko lalo na kapag by grimace and interventions the the patient felt
umuubo ako” as guarding behavior. patient will be able to Observer and monitor To identify changes and improvement with his
verbalized by the rest in a semi or fowler V/S acts as a baseline. chest, verbalized
patient. position. relieved pain, rested
and coped up with pain
Long Term Goal: Administer medications To relieve the pain. and do some relaxation
After 8 hour of nursing as ordered. techniques.
Objective: intervention the patient
Grimace Can rest and cope with Encourage adequate To prevent fatigue that
Guarding behavior pain and do some rest periods. can impair ability to
relaxation technique.. manage or cope with
•Pain scale: 7/10 pain.
Subjective: Activity intolerance Short term Goal: Establish guidelines Motivation and After 48 hours of
“Lagi akong pagod.”As related to imbalance After 4 hours of nursing and goals of activity cooperation are nursing intervention the
stated by the patient. between oxygen supply intervention the patient with the patient and/or enhanced if the patient patient is able to
and demand as will have normal pulse SO. participates in goal
maintain activity level
evidence by rate, systemic blood setting
cardiopulmonary pressure and within capabilities as
status. respiratory response. Evaluate the need for Coordinated efforts are evidenced by normal
Objective: additional help at more meaningful and vital signs during
Fatigue Long term Goal: home. effective in assisting activity, as well as
Fever After 8 hours of nursing the patient in absence of weakness,
intervention the patient conserving energy. pain, and difficulty
T= 380c will be able to do ADLs
accomplishing tasks.
P= 100 bpm alone and to participate Have the patient Helps in increasing the
R= 30bpm in self-care activities. perform the activity tolerance for the intervention
B/P= 110/70 mmHg more slowly, in a longer activity.
time with more rest or
pauses, or with
assistance if
necessary.
“nalilito ako kung Risk for ineffective Short term Goal: Allow patient’s Patients who After 12 hours of
anong gamut ang therapeutic regimen After 1 hour of nursing participation in planning participate in their care nursing intervention the
inumin ko" as stated by management related to intervention the patient the treatment program. have a greater chance patient will verbalize
complexity of will absorb or recognize of obtaining a positive
the patient . how important to follow
therapeutic regimen the desired health- result.
that patient must follow related activity. the treatment plan and
Objective: as evidence by Tell the patient about Patients who how would affect his
Confused verbalized difficulty of Long term Goal: the advantages of understand the heath if he will not
taking the prescribed After 2 hours of nursing adhering to the effectiveness of the comply.
medicine. intervention the patient prescribed regimen. suggested treatment to
will understand the reduce risk or to
effect of not following promote health are
the implementation of more likely to engage
the treatment plan. in it.
Avoid unnecessary
clinic visits. The physical
requirements of going
to an appointment, the
financial costs incurred
(loss of day’s work,
child care), the
negative feelings of
being “talked down to”
by healthcare providers
not fluent in the
patient’s language, as
well as the commonly
long waits can cause
patients to withdraw
themselves from follow-
ups.
Develop with the
patient a method of Rewards may consist
rewards that follow of verbal recognition,
successful follow- monetary rewards,
through. special privileges
Subjective: Risk for Infection Short Term Goal: Review pathology of Helps patient realize/ After 12 hours of
“ubo ako ng ubo, Transmission related to After 12 hours of disease and potential accept necessity of nursing interventions,
natatakot ako baka airborne transmission nursing interventions, spread of infection via adhering to medication the patient was able to
exposure as evidence the patient will be able airborne droplet during regimen to prevent
mahawaan ko pamilya verbalized and
by Infection of to Identify interventions coughing, sneezing, reactivation/complicatio
ko as stated by the pulmonary tuberculosis to prevent/reduce risk spitting, talking, n. Understanding of acknowledged on what
patient. as health threat. of spread of infection laughing and singing. how the disease is to do to prevent/reduce
passed and awareness risk of spread of
Objective: Long term Goal: of transmission infections.
After 72 hours of possibilities help .
T= 380c nursing intervention the client/SO take steps to
P= 100 bpm patient demonstrate prevent infection of
R= 30bpm techniques/initiate others.
B/P= 110/70 mmHg lifestyle changes to
promote safe Identify others at risk; Those exposed may
environment. e.g., household require a course of
members, close drug therapy to prevent
associates/friends. spread/development of
infection.
Collaborative