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ASSESSMENT SUBJECTIVE: Nahihirapan akong huminga as verbalized by the patient. The client complained of difficulty of breathing and chest tightness. OBJECTIVE: The client exhibits: Nasal flaring Orthopnea Non-productive cough Presence of adventitious breath sound (Wheezes) Poor nail bed capillary refill Cyanosis V/S taken: BP: 110/80 mmHg PR: 108 bpm RR: 29 cpm TEMP: 38.3 oC
DIAGNOSIS Ineffective airway clearance due to airway spasm, related to bronchial asthma in acute exacerbation.
ANALYSIS IMMINENT CAUSE: Hypoxia due to poor oxygen intake. INTERMEDIATE CAUSE: Bronchospasm due to allergic reaction. ROOT CAUSE: Exposure of the client to antigens.
PLANNING After 8 hours of nursing interventions, the client will be able to: GOALS: Verbalize her understanding about the causes of the disorder and the therapeutic management regimen associated with it.
IMPLEMENTATI ON INDEPENDENT: Monitor respirations and breath sounds, noting rate and sounds (tachypnea, stridor, crackles, and wheezes). Elevate head of bed and change position every 2 hours and PRN.
RATIONALE
EVALUATION After 8 hours of nursing interventions, the client was able to:
Breathe without
Identify
To take advantage of gravity decreasing pressure on the diaphragm and enhancing ventilation to different lung segments.
There was no adventitious breath sounds noted during inhalation and exhalation. RR went down to 20 cpm GOAL MET
To avoid
exacerbation of the d/o into a more life threatening condition (status asthmaticus).
Demonstrate
clear breath sounds, noiseless respiration, and improved O2 exchange (absence of cyanosis, ABG and O2 sat results are with in normal range).
Assist with
ASSESSMENT SUBJECTIVE: Nahihirapan akong huminga dahil sa plema as verbalized by the patient. The client complained of difficulty of due to excessive mucus production. OBJECTIVE: The client exhibits: Nasal flaring Dyspnea Productive cough Presence of adventitious breath sound (Crackles) V/S taken: BP: 110/80 mmHg PR: 108 bpm
DIAGNOSIS Ineffective breathing pattern due to airway obstruction, related to bronchial asthma in acute exacerbation.
ANALYSIS IMMINENT CAUSE: Hypoxia due to poor oxygen intake. INTERMEDIATE CAUSE: Mucus production due to allergic reaction. ROOT CAUSE: Exposure of the client to antigens.
PLANNING After 8 hours of nursing interventions, the client will be able to: GOALS: Verbalize her understanding about the causes of the disorder and the therapeutic management regimen associated with it.
IMPLEMENTATI ON INDEPENDENT: Monitor respirations and breath sounds, noting rate and sounds (tachypnea, stridor, crackles, and wheezes). Increase fluid intake to at least 2000 mL/day within cardiac tolerance Suction naso/tracheal/o ral PRN
RATIONALE
EVALUATION After 8 hours of nursing interventions, the client was able to:
Breathe easily
Identify
Hydration can help liquefy viscous secretions and improve secretion clearance. To clear airway when excessive or viscous secretions are blocking airway or client is unable to swallow or cough effectively
without any complaint of shortness of breath due to excessive mucous production and chest tightness.
There was no adventitious breath sounds noted during inhalation and exhalation. RR went down to 20 cpm GOAL MET
Demonstrate
absence of congestion with clear breath sounds, noiseless respiration, and improved breathing pattern. (absence of cyanosis, ABG and O2 sat results are with in normal range).
To help liquefy
the mucus.
Assist with
ASSESSMENT SUBJECTIVE: Tatlong araw na masakit ang tagiliran ko kasabay ng lagnat as verbalized by the patient. The client complained of flank pain and fever for 3 days. OBJECTIVE:
DIAGNOSIS Acute pain as evidenced by facial grimace accompanied with fever. Flank pain refers to pain on one side of the body between the upper abdomen and at the back. If the flank pain is accompanied by fever, chills, blood
ANALYSIS IMMINENT CAUSE: Narrowed focus and reduced interaction with people and environment due to acute pain. INTERMEDIATE CAUSE: Inflammation of urinary tract. ROOT CAUSE:
PLANNING After 8 hours of nursing interventions, the client will be able to: GOALS: Demonstrate the use of relaxation techniques as indicated for individual situation.
IMPLEMENTATI ON INDEPENDENT: Obtain clients assessment to pain which includes location, characteristics, onset and duration. Provide comfort measures (touch), quiet environment and calm activities.
RATIONALE
EVALUATION After 8 hours of nursing interventions, the client was able to: Verbalize relief of pain. Temperature went down to 37.8
To rule out
GOAL
PARTIALLY MET
The client exhibits: Facial grimace with pain quality of 3/5. V/S taken: TEMP: 38.3 oC
in the urine, or frequent urination, then a kidney problem is the likely cause. (Saunders; Medical-Surgical Nursing; 8th ed., chap 10.)
Verbalize nonpharmacologica l methods that provide relief. OBJECTIVES: Relieved of pain. Maintain a body temperature within normal range.
To distract attention and reduce tension. To regulate body temperature within normal range. To decrease pain sensation thus decreasing the clients anxiety towards pain.