Jerome Felicitas IV Ivory

Assessment S: marigatan nak aganges adding ko as verbalized by the patient O: o Nasal flaring o Respiratory depth changes Use of accessory muscles Difficulty of Breathing RR= 103 bpm o Diagnosis Ineffective breathing pattern related to decrease d lung expansion secondary to accumula tion of fluid in the pleural cavity. Analysis There is the accumulation of fluid in the pleural cavity, limiting the expansion of the lungs during inhalation. This causes ineffective breathing pattern. Planning Goal: o The client will be able to maintain effective lung expansion after 8 hours of effective nursing o intervention. EO: After 8 hours, the client will be able to: -have respirations within normal range Intervention Monitor vital signs especially RR. o Rationale To determine manifestations of ineffective breathing and for early initiation of intervention. to assess symptoms of cerebral hypoxia to facilitate proper breathing pattern Evaluation Goal Partially Met: The client was partially able to maintain effective lung function after 8 hours of intervention.

Assess for restlessness Position client to high fowlers position Teach relaxation techniques or exercises Administer prescribed oxygen

to reduce anxiety and improve ventilation

o o

to temporarily relieve hypoxia brought by ineffective breathing pattern

Assessment S: Medyo agkakapsot nak.. as verbalized by the client. O: o bedrest, immobility o generalized weakness pale and weak in appearance o

Diagnosis Activity intoleranc e related to bedrest/ immobility aeb verbal report of weakness.

Analysis The patient has ineffective breathing pattern, decreasing his intake of oxygen into his body. Because of that, the body couldnt tolerate activities of daily living.

Planning Goal: The patient will be able to improve activity tolerance after 8 hours of intervention. EO: The patient will be able to do the ff. after 8 hours: o

Intervention Monitor vital signs o

Rationale to recognize early signs of fatigue and anticipate needs to acquire cooperation

Evaluation Goal Partially Met: The client partially improved his tolerance on the performance of ADLs.

o o Teach patient/family the importance of mobilization o Encourage patient to mobilize her limbs by doing flexion and extension o Encourage significant others to participate in care o Encourage rest to patient

-to verbalize understanding of o the importance of mobilization -to perform ROM on all joints -to show tolerance of exercise

to facilitate blood flow and gradually promote independence and tolerance to provide encourageme nt and enjoyment

to build endurance and energy for any activity

Assessment S: No verbal complaint. O: o open lesions on the skin o

Diagnosis Risk for infection rt impaired skin integrity

Analysis As the bacteria invades the body, it damages the nerves and even causes formation of skin lesions in the skin, impairing skin integrity. This predisposes the client to infection.

Planning Goal: The patients risk for infection will decrease after continuous effective nursing intervention. EO: After intervention, the patient will be able to: o -develop no signs or symptoms indicating infection -demonstrate knowledge about measures to prevent infection o

Intervention o Monitor vital signs o o Handwashing should be practiced by both health personels, patient himself and his family Practice aseptic technique in care of the wound Monitor wounds especially the open lesions Increase I&O of client o

Rationale to detect change in status of client to prevent transmission of microorganism s and to prevent contamination

Evaluation Goal partially Met: The patients risk for infection partially decreased after continuous intervention. This is because damaged skin is still open and not fully healed.

to prevent contamination / infection to detect any redness, or drainage from the wound that may indicate infection to hydrate the skin and prevent further skin breakdown