Nursing Problem / Cues Ineffective airway clearance related to retained secretions in the bronchi secondary to Pulmonary Tuberculosis Subjective:

He said that he was having coughs for 3 weeks The symptoms he verbalized are fever and loss of appetite Client has history of hemoptysis He vomited blood

Analysis Ineffective airway clearance is the inability to clear secretions/obstructi ons from the respiratory tract to maintain a clear airway.

Patients Name : RDB Goal and Objectives

Lim, Lorelie F. Goal: Group 69 of the 8At the end hour shift,FAR EASTERN UNIVERSITY the client NSTITUTE will be ableIto have OF NURSING improved airway N clearance as URSING CARE PLAN manifested by: a. effective (Nurses Pocket Guide coughing of 11th edition by Marilynn secretions E. Doenges page 77) b. verbalization of relief from DOB The individual experiences a threat Objectives: to respiratory status After nursing 1a. Assess clients related to inability intervention, the knowledge of to cough effectively. client will be able to: contributing causes, It may be caused by treatment plan, pleural pain, 1. verbalize specific medications, decreased energy knowledge in and therapeutic and fatigue, and the importance procedures increased sputum of effectively production. The expectorating 1b. Provide specific cause for secretions information about the the client is the necessity of raising increased sputum and expectorating production. secretions versus swallowing them

Age: 33 Nursing Intervention BSN118

Rationale

Evaluation At the end of the 8-hour shift, client has improved airway clearance as manifested by: a. effective coughing of secretions b. verbalizati on of relief from DOB

1a. modalities to manage secretions and improve airflow vary according to clients diagnosis 1b. to report changes in color and amount in the event that medical intervention may be needed to prevent/treat infection

Objective: Weak in appearance Pale nail beds and lips Abnormal respiratory rate and depth RR- 26cpm irregular and deep respiration 2. maintain adequate and patent airway.

1c. Demonstrate client in performing specific airway clearance techniques such as forced expiratory breathing, etc. 1d. Encourage opportunities for rest 2a. Monitor respirations and breath sounds, noting 2a. indicative of respiratory distress and/or accumulation of secretions

FAR EASTERN UNIVERSITY INSTITUTE OF NURSING NURSING CARE PLAN

Jacob, Aileah Rose

BSN118 Group 69

Nursing Problem/Cues Pain r/t excessive strain on chest from coughing Subjective: Client reported decreased appetite Client verbalized presence of chest pain Objective: Coughing Facial grimace was observed Client is soft spoken and is cautious everytime he speaks Client manifested guarding behavior Respiratory rate = 26 cycles per minute

Goal and Intervention Objectives Pain refers to Goal: the unpleasant At the end of the sensory and shift, the FAR EASTERN UNIVERSITY client will NSTITUTE OF NURSING emotional have relief Ifrom experience pain. NURSING CARE PLAN arising from actual or Objectives: potential tissue After 30 minutes damage or of nursing described in intervention, the terms of such client will be able 1. Monitor vital signs damage. to: particularly the It may be related 1. Have stable respiratory rate to injuring vital signs 2.a.Provide comfort agents which measures includes >touch biological, 2. Have >nurses presence chemical, decreased pain >calm activities physical, and rate from 7/10 2.b. Encourage use psychological. to 3/10 of relaxation techniques >focused breathing 2.c encourage diversional activities >reading >socialization with others 2.d Administer antitussives as ordered 2.e. identify ways of avoiding/minimizing pain > limit movements > adequate rest periods 3. Reassess pain 3. Have pain regularly monitored

Analysis

Rationale

Evaluation Goal: At the end of the shift, the client was able to have relief from pain. Objectives: After 30 minutes of nursing intervention, the client was able to: Have stable vital signs Have decreased pain rate from 7/10 to 3/10

To monitor for any alterations. To promote nonpharmacologi cal pain management

To distract attention and reduce tension

To suppress but not obliterate coughing

Have pain monitored

Verbalize relief of pain To rule out worsening of underlying

4. Verbalize relief of pain

4.Allow client to verbalize feelings

FAR EASTERN UNIVERSITY INSTITUTE OF NURSING NURSING CARE PLAN

Alminar, Querobin M. Group 69 Nursing Problem / Cues Activity intolerance related to generalized weakness Subjective: Client report weakness The client verbalized, iniiwasankomag lalakad-lakad. Nanghihina pa kasiako He mentioned that he doesnt Analysis Activity intolerance refers to Insufficient physiological or psychologica l energy to endure or complete required or desired daily activities. Nurses Goal and Objectives Goal: At the end of the 8 hour-shift the client will be able to participate in necessary/desired activities within capabilities as evidenced by absence of weakness and normal respiration rate and depth

BSN118

Intervention

Rationale

Evaluation After rendering 8 hours of nursing intervention, the client was able to participate in necessary/desired activities within capabilities as evidenced by absence of weakness and normal respiration rate and depth

FAR EASTERN UNIVERSITY INSTITUTE OF NURSING NURSING CARE PLAN want to go to the rest room because he feels he might expectorate blood and he added that he feels weary. Objective: Weak in appearance Pale nail beds and lips Abnormal respiratory rate and depth RR- 26cpm irregular and deep respiration with occasional sighing Pocket Guide 11th edition by Marilynn E. Doenges page 70 Objectives: After rendering nursing interventions, the client will be able to: Most activity A. Identify intolerance is causative/p related to recipitating generalized factors weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in elderly patients with a history of orthopedic, cardiopulmo nary, diabetic, or pulmonaryrelated problems. T

Determine patient's perception of causes of fatigue or activity intolerance. Note client reports of weakness, fatigue, pain, difficulty accomplishing tasks, and/or insomnia. Assess patient's level of mobility.

Assessment guides treatment. This will also give direction in establishing goals Symptoms may be result of/or contribute to intolerance of activity This aids in defining what patient is capable of, which is necessary before setting realistic goals. To determine current status and needs associated with participation in needed/desired activities Adequate energy reserves are required for

Ascertain ability to stand and move about and degree of assistance necessary/use of equipment. Assess nutritional status

FAR EASTERN UNIVERSITY INSTITUTE OF NURSING NURSING CARE PLAN activity. Assess potential for physical injury with activity. Monitor patient's sleep pattern and amount of sleep achieved over past few days B. Perform techniques to enhance activity tolerance Assess emotional response to change in physical status. Injury may be related to falls or overexertion. Difficulties sleeping need to be addressed before activity progression can be achieved Depression over inability to perform required activities can further aggravate the activity intolerance. Rest between activities provides time for energy conservation and recovery.

Encourage adequate rest periods, especially before meals, other ADLs, exercise sessions, and ambulation. Assist with ADLs as indicated; however, avoid doing for patient what he or she can do for self.

Assisting the patient with ADLs allows for conservation of

FAR EASTERN UNIVERSITY INSTITUTE OF NURSING NURSING CARE PLAN energy. Caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the patient's activity tolerance and selfesteem. This reduces energy expenditure This prevents overexertion and promotes attainment of goals.

C. Verbalize measurable increase in activity tolerance Provide bedside commode as indicated (if available). Progress activity gradually -Active range-ofmotion -Dangling 10 to 15 minutes three times daily -Deep breathing exercises three times daily -Sitting up in chair 30 minutes three times daily -Walking in room 1 to 2 minutes three times daily -Walking in hall 25 feet or walking around the house, then slowly progressing

FAR EASTERN UNIVERSITY INSTITUTE OF NURSING NURSING CARE PLAN Teach patient/caregivers to recognize signs of physical over activity Teach the importance of continued activity at home. Teach energy conservation techniques. Like: Sit. Standing requires more work. Changing positions often. This distributes work to different muscles to avoid fatigue. Push rather than pull Slide rather than lift Rest for at least 1 hour This promotes awareness of when to reduce activity.

This maintains strength, ROM, and endurance gain. These reduce oxygen consumption, allowing more prolonged activity.

FAR EASTERN UNIVERSITY INSTITUTE OF NURSING NURSING CARE PLAN after meals before starting a new activity. Ene rgy is needed to digest food. Organize a work-restwork schedule Encourage patient to verbalize concerns about discharge and home environment. These reduce feelings of anxiety and fear.