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    CORPUZ QQQ

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    Romm Jacob
    The client's condition improved with nursing interventions.

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    CORPUZ QQQ

    Uploaded by

    Romm Jacob
    29 views3 pages
    The client's condition improved with nursing interventions.

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    CORPUZ-qqq

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    © © All Rights Reserved

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    The client's condition improved with nursing interventions.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    29 views3 pages

    CORPUZ QQQ

    Uploaded by

    Romm Jacob
    The client's condition improved with nursing interventions.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    CORPUZ, Althea Louise R.

    October 3, 2023
    UB SON BSNII / NBD2 NCLMCA1: OB-GYNE WARD, BONTOC GENERAL HOSPITAL

    Patient: Paleg, H.
    Chief Complaint: Dry Cough
    Nursing Diagnosis: Ineffective breathing pattern related to bronchospasm, decreased lung expansion as evidenced by heavy breathing, hoarse voice, nasal flaring and frequent clearing of
    throat

    ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION


    Subjective Data: Ineffective breathing pattern STO: Dx: Dx: STE:
    related to bronchospasm, After 2 hours of nursing After 2 hours of nursing
    "marigatan nak aguyek decreased lung expansion as interventions, the client will 1. Assessed present 1. Presents the baseline interventions, the goal was
    gamen dry jay cough ko evidenced by heavy be able to perform breathing health status by data for any changes or met. Patient was able to
    ngay" as verbalized by the breathing, hoarse voice, nasal exercise and lessen throat monitoring vital signs fluctuations in pain and perform breathing exercise.
    patient. flaring and frequent clearing clearing. discomfort.
    of throat LTE:
    Objective Data: LTO: 2. Assessed the client’s 2. To identify and assess After 2 days of nursing
    Vital signs noted as: After 2 days of nursing perception, level of the nursing intervention, the goal was
    interventions, the client will understanding and interventions to be met. Patient was able to
    RR: 22, PR: 83, T:36.1, BP: be able to establish normal needs done. established normal and
    110/70, SPO2: 97 and effective respiratory effective respiratory
    breathing pattern. Slight to no 3. Administered breathing pattern. No nasal
    - frequent clearing of throat; nasal flaring. Restore health Salbutamol for 3. To clear patient’s flaring. Restored health
    with rapid and shallow status. nebulization as airway and relieve chest status.
    breathing. Exhibits nasal ordered. tightness, wheezing and
    flaring. coughing.
    Tx: Tx:
    1. Assisted in a 1 Promotes maximal
    comfortable inspiration; enhance
    position. (Semi- lung expansion and
    Fowler’s or High ventilation.
    Fowler’s Position)
    2 Presence of allergen
    2. Keep environment may trigger allergic
    allergen free (dust, response that may
    feather pillows, cause further
    smoke, pollen) coughing.

    3. Assist the client in 3 Reduces fatigue


    controlled coughing associated with
    undirected coughing.
    .
    4. Assist the client in 4 Breathing exercises
    doing breathing increases oxygen
    exercise. intake and can help
    alleviate heavy
    breathing.
    EDx EDx
    1. Encouraged patient 1. Increased mucus
    to increase fluid and sputum
    intake to 8-10 secretions can
    glasses a day lead to
    dehydration;
    2. Teach purse-lip increased fluid
    breathing, abdominal intake dissolve
    breathing, and secretions and
    performing help moisten the
    relaxation techniques throat.
    to the patient
    3. Encourage frequent 2. These measures
    rest periods and allow the patient
    teach the patient to to participate in
    pace activity Maintaining
    health status and
    improved
    4. Educate the patient ventilation.
    about the indication,
    dosage, frequency, 3. Extra activity can
    and possible side worsen shortness
    effects of prescribed and heavy
    medications. breathing. Ensure
    the patient rests
    between
    strenuous
    activities.

    4. Knowing side
    effects and proper
    usage of
    medications
    ensures the best
    possible
    treatment.

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