hyperthermia related to altered thermoregulatory process, secondary to infection.

ASSESSMENT S, napudot ti riknak !, fe rile! with a temperature of "#.$%& > 'kin warm to touch >presence of diaphoresis >weak in appearance >dr( lips >poor skin turgor > Increased respirator( rate. A, )(perthermia related to altered thermoregulator( process! secondar( to infection.

PAT !P "S#!$!%" Anopheles mos*uito + In,ects parasites in the lood of a person + In-ades ./& where the( grow and undergo ase0ual propagation + ./& ruptures or ursts releasing tin( organisms + 1/& macrophages produces interleukin + &auses h(pothalamus to release prostaglandin 2 + .aises set point oh h(pothalamus + )eat production and conser-ation + h(perthermia

!&'E(T#)E ST!> after 1 hour of nursing inter-ention! the patient3s temperature will e lowered from "#.$%& to the normal range of "$.#%& - "4.5%&

#NTE*)ENT#!NS ./> :onitor and record -ital signs! and taking note on temperature

*AT#!NA$E > :onitoring -ital signs pro-ides a aseline data! in the situation the patient has )(perthermia! assessing the temperature will check if the patient has irregularities in temperature. > )(perthermia can cause se-ere loss of water in the od(! due to sweating! and micturating. > 20cess clothing and linens will raise the temperature! remo-ing it can make a cool en-ironment. > can pro-ide a cool skin surface! thus decreasing od( temperature. > =aracetamol relie-es fe-er ( central action in the h(pothalamic heat regulating center. > To replace the fluid lost. > >oods rich in ?it &! oosts the immune s(stem@ response. > To gi-e a cool en-ironment.

E)A$+AT#!N ST!>Goal will e met if the patients temperature will e in the normal range of "$.#%& - "4.5%& >Goal is not met if the patients temperature still remains higher than the normal od( temperature $T!> Goal met if the patient will not e0perience h(perthermia during the course of hospitali6ation and can -er ali6e the importance of a89eeping a cool en-ironment 8tepid sponge aths c8 taking paracetamol for temperature of "4.#%& >goal is unmet if the patient still ha-e fe-er and cannot -er ali6e the importance of cool en-ironment! T'/ and taking paracetamol.

> Assess h(dration status. T/> .emo-e e0cess clothing! and linens.

$T!>after 2-" da(s of nursing inter-entions! the patient will not e0perience h(perthermia and can -er ali6e some inter-entions to decrease temperature like7 a89eeping a cool en-ironment 8tepid sponge aths c8 taking paracetamol for temperature of "4.#%&

> ;o T'/ <tepid 'ponge ath8. > Gi-e paracetamol as ordered. Ed/> encourage patient to drink 1% glasses of water! instead of $ glasses. >2ncourage the patient to eat foods rich in -itamin &! such as calamansi! orange or lemon >Instruct the client to remo-e e0cess clothing

Nutritional imbalance less tan body requirements related to lack of appetite. ASSESSMENT S, Awan ganas ko nga mangan PAT !P "S#!$!%" Intake of nutrients !&'E(T#)E ST!> After 1-2 hours of #NTE*)ENT#!NS ./> Assess general health status. *AT#!NA$E > To note for other conditions that E)A$+AT#!N ST!Goal met if the patient will

insufficient to meet meta olic needs. !, limited mo-ements > weak in appearance > conscious and coherent > did not finished the food gi-en! eating onl( 25A of the food ser-ed. > afe rile with a temperature of "$.B%& > has a weight of 5$kgs. A, Cutritional im alance less tan od( re*uirements related to lack of appetite.

Cursing inter-entions! the client will understand and -er ali6e the importance of proper nutrition.

> assess for eating ha its! including food preferences. > Assess weight! age and od( weight. >Assess and record -ital signs >Cote total dail( intake patterns and times of eating. T/>encourage -er ali6ation of feelings and concerns > assisted in patients needs Ed/> encourage patient to choose foods that are7 a8 appealing 8 nutritious >emphasi6ed the importance of eating well alanced and nutritious diet.

affects health! or those that affect wh( the patient don3t like to eat. > To determine the content of meal which would identif( the patient3s intake of food is nutritious. > pro-ides comparati-e aseline. > pro-ides a aseline data > To re-eal changes that should e made in a client3s dietar( intake. > to know the perception of the patient on the pro lem! and thus promotes patient interaction. > can decrease fatiga ilit(! so that the patient can conser-e energ(. > to stimulate appetite >to attain a health( status >to pre-ent further complication of disease! and to maintain health.

understand and -er ali6e the importance of proper nutrition. Goal is unmet! if the patient cannot understand and -er ali6e importance of proper nutrition.

$T!> After 2-" da(s of nursing inter-entions the patient will demonstrate eha-iors! lifest(le changes to regain and maintain appropriate weight.

$T!>goal will e met if the patient demonstrate changes in appetite that will increase his od( weight. > Goal is partiall( met! if he patients weight is still 5$kgs! and demonstrate a little on the eha-iors that will increase his weight. > Goal is unmet! if he patients weight! goes lower than 5$kgs.

#mpaired skin integrity related to tissue trauma, secondary to electrical burns. ASSESSMENT S, Cagatel da(to( sugat ko! dito( singit! ti(an ken dito( and points at the chest !,redness around the urned site. >with lesions noted on the legs! arms! chest! a domen and inguinal area >with dressing noted on the chest and a domen >with clean and dr( dressing. >disruption of skin la(er noted. >destruction of skin la(er noted A, Impaired skin integrit( related to tissue trauma! secondar( to electrical urns. E0P$ANAT#!N !1 T E P*!&$EM 2lectrical urns Tissue truma Impaired skin integrit( !&'E(T#)ES 'TD7 after 1 hour of nursing inter-entions the patient should e a le to demonstrate eha-iors on how to promote healing and pre-ention of skin reakdown. ETD7 after 2-" da(s of nursing inter-ention the patient will e a le to achie-e timel( wound healing without ha-ing complications. N+*S#N% #NTE*)ENT#!N ;07 >monitor and record -ital signs >assess general status >assess skin integrit( T07 > edside care done >regulate the a o-e I?> to its desired flow rat 2d07 >discuss the importance of proper wound care >encourage patient to -er ali6e his feelings and concerns >encourage to eat foods rich in protein. >encourage to drink 1% glasses of water dail(! instead of 4 glasses. *AT#!NA$E >this will indicate complications. And it also acts as a aseline data. > 9now degree of immo ilit( in order to render appropriate nursing inter-ention > to determine if the patient de-elops rashes! or deh(dration >can pre-ent the patient from ha-ing edsore! and can also help the patient not to de-elop infection. >to a-oid de-elopment of fluid -olume e0cess. >a-oid further infections >to assess for further complications. >promotes patient interaction. >protein helps in issue repair >to a-oid the risk of ha-ing deh(dration E)A$+AT#!N 'TD7 The goal was met ecause the patient was a le to demonstrate correct techni*ues on proper wound care

ETD7 Goal was met ecause the patient was a le to demonstrate proper wound care .

#mpaired physical mobility related to tissue trauma, secondary to electrical burns.

ASSESSMENT '> :arigatanak nga agkuti gapu dito( sugat ko. D>limited range of motion >slowed mo-ement >perform acti-ities of dail( li-ing with assistance >difficult( in turning and mo-ing in ed >with lesions noted on the legs! arms! chest! a domen and inguinal area >with dressing noted on the chest and a domen A>Impaired ph(sical mo ilit( related to tissue trauma! secondar( to electrical urns.

E0P$ANAT#!N !1 T E P*!&$EM

!&'E(T#)ES 'TD7 After "%-F5 mins. of nursing inter-ention! the patient will e a le to understand and -er ali6e a8 Importance of earl( am ulation. 8 =roper compliance to medication. .18 patient -er ali6e that she needs to take medications with the right dose at the right time. .28 a le to enumerate the importance of compl(ing to medications

N+*S#N% #NTE*)ENT#!N ;07 > Assess muscle strength > Assess general status > ;etermine degree of immo ilit( > Assess degree of pain > Assess eha-ioral and emotional responses to pain T0 > Assist patient to reposition in ed

*AT#!NA$E >;etermine patients a ilit( to mo ili6e self >9now degree of immo ilit( in order to render appropriate nursing inter-ention >To pro-ide appropriate inter-entions and le-el of care to e rendered. > ;egree of pain contri utes to immo ilit( > Cote factors affecting pain and coping that ma( impede goal attainment. > =re-ent the patient from e0erting too much effortH it also impro-es lood circulation that ma( aid in making the healing process faster. >:a0imi6e energ( and strength of the patient. >.estore strengthH impro-e lood circulation to aid in faster healing of incisionH a-oid cohesion of internal organs. > 20ercises like these can contri ute to rela0ation of muscle tension and relief pain and pro-ide comfort to the patient. >.educes fatigue. > 2nhance self concept and promote rest. > /e a le to render appropriate and effecti-e nursing care. > 2nhance self-concept and promotes independence. > =romote well- eing and ma0imi6e energ( productionH )elps in faster wound healing and restore or replace lost od( nutrients. > .estore strength! impro-e lood circulation! aid in faster healing and pre-ent cohesion of microorganisms.

E)A$+AT#!N 'TD7 The goal was met ecause the patient was a le to understand and -er ali6e the ff A. Importance of earl( am ulation. a.18 for good circulation to promote faster healing. a.28 to pre-ent adhesion of intestines. /. Importance of =roper compliance7 .18 patient -er ali6ed that he needs to take medications with the right dose at the right time. .28 a le to enumerate the effecof compl(ing with medications. ETD7 Goal was met ecause the patient was a le to7 ;emonstrate .D: e0ercise like fle0ion Ge0tension of lower e0tremities. :o ili6ation like walking from ed to &. and -ise -ersa! and performing and repositioning self with or without assistance.

2lectrical urn Tissue trauma .elease of neurotransmitters such as rad(kinin! histamine and prostaglandin 'timulate ner-e impulse across the ner-e s(napse from the primar( afferent neuron to the dorsal horn Transmission of signals to the thalamus 'omatic sensor( corte0 of the rain =erception and meaning =ain is felt Impaired ph(sical mo ilit(

> Assist in performing acti-ities of dail( li-ing > Assist patient to am ulate

> ;emonstrate deep reathing and range of motion e0ercises. >=ro-ide ade*uate hours of rest and sleep >=ro-ide comfort ( stretching linens 2d0 > 2ncourage patient to -er ali6e feelings and concerns > 2ncourage patient to participate in acti-ities as tolerated. > 2ncourage intake of fluid and nutritious foods especiall( foods rich in protein like fish! legumes eans and meat. > 2ncourage patient to am ulate for at least 5-4 2F hours post operati-el(.

ETD7 After 2-" da(s of nursing inter-ention the patient will7 a8 ;emonstrate .D: e0ercise like fle0ion Ge0tension of lower e0tremities. 8 :o ili6ation like walking from ed to &. and -ise -ersa! performing and repositioning self with or without assistance.

Sleep pattern disturbance due to en2ironmental factors. ASSESSMENT s> haanak mas(ado nga makaturog! gamin nainga( dito(! ken ,a( pag /= da kan(ak o> patients look irrita le >looks sleep( and ha-e droop( e(es >conscious and coherent > slowed reaction a> 'leep pattern distur ance due to en-ironmental factors. E0P$ANAT#!N !1 T E P*!&$EM Coise coming from neigh oring patients and -ital signs monitoring during night time. + =atient is awakened + 'leep pattern distur ance !&'E(T#)ES 'TD> after 1-2 hours of nursing inter-entions! the patient would e a le to enumerate wa(s on how do di-ert attention from en-ironmental noises. >patient would e a le to do rela0ation techni*ues such as deep reathing e0ercises. ETD> after 2-" da(s of nursing inter-entions! the patient would e a le to -er ali6e complete ed rest and show signs of well rested appearance. N+*S#N% #NTE*)ENT#!NS ;0 >assess the general appearance of the patient > assess contri uting factors to rule out complications. *AT#!NA$E > ;roop( e(es and dark color under lower e(elids are indicati-e of lack of sleep. >identif( factors that contri utes to sleep patterns distur ances like con-ersations done ( other patients! uncomforta le ed and identif( factors that could help minimi6e distur ances and help patient rela0 like fi0ing his ed and con-ersing with the patient. >good personal h(giene could decrease irritation to the od( that ma( stimulate scratching and waking self >pro-ide a comforta le sleeping area >minimi6e noise and distur ance and to promote rela0ation and sleep. >ad-ocate etter rest 2d0 > recommend limit intake of chocolate and caffeine especiall( prior to edtime. >ad-ice patient to limit fluid intake in the e-ening or efore ed time. > recommend midmorning nap than afternoon nap. >chocolate and caffeine contains su stances which would interfere with the patients sleep. >to a-oid urinating at night. >afternoon naps make it harder for the patient to sleep at night. E)A$+AT#!N 'TD > o ,ecti-e full( met7 >the patient is cooperati-e and is a le to enumerate and demonstrate on how to di-ert attention! and rela0ation techni*ues such as deep reathing e0ercises. ETD >Goal met7 >the patient was a le to -er ali6e complete ed rest and showed signs of well rested appearance.

>assess personal h(giene. T0 > maintain cleanliness and order of patients ed. >pro-ide *uiet en-ironment and comfort measures such as cleaning and straightening linens. >pro-ide proper -entilation.

3no4ledge deficit related to lack of e/posure

ASSESSMENT '> ano a ang incomplete a ortionI o> good skin turgor >afe rile A> 9nowledge deficit related to lack of e0posure

E0P$ANAT#!N !1 T E P*!&$EM Eack of e0posure to the pro lem The patient asks *uestions to her situation 9nowledge deficit

!&'E(T#)ES 'TD7 After 1 hour of nursing inter-entions the patient will e a le to7 a. =articipate in learning process . 20hi it increase Interest And egins to look for information and ask *uestions. c. ?er ali6e understanding of the condition and the patient can answer *uestions a out situation. ETD7 After 2 da(s of nursing inter-entions that patient will e a le to7 A. identif( signs and s(mptoms of the disease and correlate s(mptoms with causati-e factors.

N+*S#N% #NTE*)ENT#!NS ;07 >assess general health status > monitor and record -ital signs >Assess the clients moti-ation T07 >determine the clients method of accessing informations > pro-ide acti-e role for the client in learning process. >pro-ide information a out additional learning resources >encourage -er ali6ation of feelings > egin with the informations the patient alread( knows. 2d07 >ad-ise patient to read ooks which contains rele-ant informations to her *uestions

*AT#!NA$E >ser-es as aseline for e-aluation. > ser-es as aseline data > to pro-ide rele-ant information3s to the situation >to facilitate learning >ma( assist for further learning! and pro-ides learning at own pace. >promotes sense of control in situation. > for patient3s participation > >or patient3s limits the sense of eing o-erwhelmed. >promotes patient participation to the learning needs

E)A$+AT#!N 'TD7 Goal >ull( met! the patient was a le to7 a. =articipate in learning process . 20hi it increase interest And egins to look for information and ask *uestions. c. ?er ali6e understanding of the condition! and had answered the *uestions raised ( the student nurse. ETD7 Goal full( met! the patient was a le to7 A. identifies signs and s(mptoms of the disease and correlate s(mptoms with causati-e factors.

#neffecti2e air4ay clearance related to accumulation of secretions in the tracheobronchial tree. Assessment S> :ed(o E/planation of the problem Inhalation of organism that !b5ecti2es ST!> After "%-F5 Nursing inter2entions ./*ationale E2aluation ST!> Goal full( met. The

nahihirapan akong huminga tapos med(o inu-u o pa ako. !> ;iminished reath sound <crackles noted on oth lung fields upon auscultation8. > .espirator( rate of 2F c(cles per minute. > /lood pressure of 11%@4% mm)g and pulse rate of B4 eats per minute. > Afe rileH TJ "4.FJ&. > &ough at times. > 1ith producti-e cough <greenish sputum noted8. > .estlessness noted. > Co c(anosis noted. A> Ineffecti-e airwa( clearance related to accumulation of secretions in the tracheo ronchial tree.

enters the respirator( tract + 'uppressed or o-erwhelmed pulmonar( defenses + :ultiplication of in-ading organisms and release damaging to0ins + Accumulation of cellular de ris and e0udates + Accumulation of secretions in the tracheo ronchial tree + Ineffecti-e airwa( clearance

minutes of nursing inter-ention the patient should e a le to demonstrate and -er ali6e eha-iors to impro-e or maintain clean airwa( such as7 a. ;eep reathing and coughing e0ercises. . Increasing fluid intake c. &hange of position e-er( two hours. d. &ompliance to prescri ed medication. $T!> After 2-" da(s of nursing inter-entions the patient should e a le to demonstrate a sence @ reduction of congestion with reath sounds clear! respirations noiseless and impro-e o0(gen e0change <e.g.! a sence of rales! crackles sound and a sence of c(anosis8.

> Auscultate for reath sounds and assess air mo-ement. > D ser-e for signs and s(mptoms of infection such as increased d(spnea with onset of fe-er and changes in sputum color. > :onitor -ital signs! noting lood pressure@ pulse changes. > D ser-e for signs of respirator( distress such as restlessness. T/> 2sta lish rapport. > =osition head midline with fle0ion appropriate for condition. > 2le-ate head of the ed@ change position e-er( two hours and as needed. > 9eep en-ironment allergen free <dust! smoke8 according to indi-idual situation. > Administer analgesics Ed/> 2ncourage deep reathing and coughing e0ercises. > Ad-ise to increase fluid intake. > 2ncourage opportunities for restH limit acti-ities to le-el of respirator( tolerance.

> To ascertain status and note progress. > To identif( infectious process@ promote timel( inter-ention. > 'er-e as aseline data. > To assess contri uting factor on patient3s progress and to deli-er appropriate nursing inter-ention. > To gain trust from the patient and the significant others. > To open or maintain open airwa( in at rest. > To take ad-antage of gra-it( decreasing pressure on the diaphragm and enhancing drainage of -entilation to different lung segments. > ;ust and smoke are precipitating factors to the patient3s condition. > To impro-e cough when pain is inhi iting effort. > )elps in e0pectoring secretions. .elie-es muscle and a dominal tension! enhances sense of control! promotes rela0ation and impro-e coping a ilities. > )elp li*uef( secretions. > =re-ents@ lessens fatigue.

patient was a le to -er ali6e and demonstrates eha-iors to maintain clear airwa(7 a. ;eep reathing and coughing e0ercises. . Increasing fluid intake c. &hange of position e-er( two hours. d. &ompliance to prescri ed medication.

$T!> Goal full( met. The patient demonstrate a sence@ reduction of congestion with clear reath sounds! noiseless respirations and impro-e o0(gen e0change <e.g.! a sence of rales! crackles sound and a sence of c(anosis8

Acute pain related to 6&( infiltration of systemic tissues, mucositis and fe2er. Assessment S> :asakit i(ong ti(an ko at alikat ko. > =atient rated pain as # out of 1%! 1% eing the highest. E/planation of the problem Altered normal cell differentiation + Eeukemia cells are immature! poorl( differentiated! and capa le of an increased rate of proliferation !b5ecti2es ST!> After F5 minutes to one hour of nursing inter-entions and health teachings the patient will e a le to -er ali6e and Nursing inter2entions ./> Assess for the le-el of pain ( ranking scale <o-1%8! reports of pain! location! *ualit(! and se-erit(. > Assess general health status. *ationale > To e a le to render a more appropriate and effecti-e nursing care. > To determine other od( parts that ma( e affected and to determine other a normalities. E2aluation ST!> Goal full( met. The patient was a le to -er ali6e her understanding of the importance of the following7 a8. coughing and deep

> =atient descri e pain as thro ing pain on sudden onset. !> )olds ack and stomach when in pain. > Grimaces noted. > 1ith limited mo-ements. > =erforms A;E with assistance. > =ulse rate of 1%1 eats per minute. > Temperature of "4.B J&. > 1ith moist uccal mucosa and lips. A> Acute pain related to 1/& infiltration of s(stemic tissues! mucositis and fe-er.

+ Eeukemia cells function a normall(! tending to crowd out normal cellsH this results in altered white and red cell acti-it( + 1/& infiltration of s(stemic tissues + :ucositis + >e-er + =erception and meaning + =ain is felt

demonstrate the following wa(s to relie-e pain7 a8. coughing and deep reathing e0ercises. 8. acti-e interaction with the people around her. c8. compliance to prescri ed pain medications. And the fe-er of the client should e lowered down to "4.5J& from initial temperature of "4.BJ&.

> =erform pain assessment each time pain occur. Cote and in-estigate changes from pre-ious reports. > Accept client description of pain. T/> =ro-ide comfort measures such as ack ru and change of position. > .eposition on a semi-fowlers position <when indicated8. > =erform T'/. > ;emonstrate deep reathing and coughing e0ercises. > Administer prescri ed medication. Ed/> 2ncourage the use of rela0ation techni*ues such as deep reathing e0ercises! listening to music and talking with significant others. > Ad-ice to compl( with the prescriptions made ( the doctor. > 2ncourage ade*uate rest period.

> To rule out worsening of underl(ing condition@ de-elopment of complications. > =ain is a su ,ecti-e e0perience and can not e felt ( others. > To pro-ide non-pharmacologic pain management. > :a( relie-e pain and enhance circulation. 'emi-fowlers position relie-es a dominal muscle tension. > To reduce fe-er. > =romotes rela0ation and relie-e pain. > )elps relie-e pain. > .elie-es muscle and a dominal tension! enhances sense of control! promotes rela0ation and impro-e coping a ilities. > =romote wellness and a-oid an( ad-erse effects that ma( e caused ( incompliance. > =re-ent fatigue.

reathing e0ercises. 8. acti-e interaction with the people around her. c8. compliance to prescri ed pain medications. And patients fe-er lowered down to "4.5J& from initial temperature of "4.BJ&.

$T!> Goal full( met. The patient was a le to rate pain as 2-" from the initial rate of # out of 1%.

$T!> After 2da(s of nursing inter-entions! the patient will e a le to rate pain as 2" from the initial rate of # out of 1%.

*isk for infection related to inadequate secondary defenses such as decreased hemoglobin and immunosuppression. Assessment !> 1ith petechiae and ecch(mosis noted on hands and feet. > Afe rileH TJ7 "$.BJ&. > 'kin is warm to touch. > =ulse rate of 1%% eats per minute. > &onscious and coherent. > &on-ersant. E/planation of the problem Altered normal cell differentiation + Eeukemia cells are immature! poorl( differentiated! and capa le of an increased rate of proliferation + Eeukemia cells function a normall(! tending to crowd out normal cellsH this results in altered white and red cell acti-it( + !b5ecti2es ST!> After "%-F5 minutes of nursing inter-ention! the patient and significant others will e a le to -er ali6e and understand7 a8 Importance of maintaining proper h(giene. a.18 pre-ent ac*uisition of infection. 8 Importance of Nursing inter2entions ./> Assess general status > Inspect skin for aseline data at least once a da(. > :onitor -ital signs <noting temperature ele-ation8. > D ser-e presence of swelling and redness. > D ser-e presence of petechiae and ecch(mosis. T/> 2sta lish therapeutic nurse patient *ationale > To e a le to render more appropriate and effecti-e nursing care. > /aseline data pro-ide criteria to measure against su se*uent assessments. > >e-er of "4.#J& ma( indicate infection. > 'welling and redness ma( manifest infection. > =etechiae and ecch(mosis are manifestations of acute leukemia. > To gain trust from the patient and the E2aluation ST!> D ,ecti-e met. The patient and significant others -er ali6ed7 a8 Importance of maintaining proper h(giene. a.18 pre-ent ac*uisition of infection. 8 Importance of increasing fluid intake and eating foods rich in proteins and -itamins. .18 help replace fluid loss

A> .isk for infection related to inade*uate secondar( defenses such as decreased hemoglo in and immunosuppression.

;ecreased hemoglo in + Immune s(stem is immunosuppressed + Eesser capacit( to defense against infection

increasing fluid intake and eating foods rich in proteins and -itamins. .18 help replace fluid loss .28 help oosts immune s(stem to a-oid occurrences of infection. $T!> After 2-" da(s of nursing inter-entions! the patient will demonstrates an a sence of infection as e-idenced ( the presence of -ital signs within normal limits! a sence of fe-er! and chills.

interaction. > =ro-ide an atmosphere of concern! openness! time as well as pri-ac( for the patient. > 2sta lish a repositioning schedule e-er( two hours. > 2ncourage client to -er ali6e feelings. Ed/, 2ncourage patient to increase fluid intake. > 2ncourage client to maintain a proper h(giene. > 2ncourage client to increase intake of protein rich foods such as fish! milk! meat! and eans and -itamins.

significant others > Time and pri-ac( are needed to pro-ide support! discuss feelings and other concerns. > &hange in position relie-e and alternate od( pressure areas! promote circulation. > =ro-ides opportunit( to identif( and clarif( misconceptions and offer emotional support. >.eplaces fluid loss due to diaphoresis or fe-er. > =roper h(giene would pre-ent ac*uisition of infection. > /oosts immune s(stem to a-oid infection.

.28 help oosts immune s(stem to a-oid occurrences of infection. $T!> D ,ecti-e met as e-idence ( a sence of fe-er and chills and presence of -ital signs within normal limits.

#mpaired physical mobility related to neuromuscular@ musculoskeletal impairment. Assessment E/planation of the problem !b5ecti2es

Nursing #nter2entions

*ationale

E2aluation

S> )aanak nga maikuti da(to( kanigid nga imak ken med(o haan nga making-ngeg da(to( kanigid nga lapa(ag ko. !> )as limited range of motionH needs assistance when turning. > 'lowed mo-ement noted. > =erforms A;Es with assistance. > 2as( fatiga ilit( noted when performing A;Es. > Gait changes noted such as decreased walking speed. A> Impaired ph(sical mo ilit( related to neuromuscular@ musculoskeletal impairment.

Arteriosclerosis + =la*ue formation + Carrowed lood -essels + Increase coagulation! decreased lood flow! h(potension! and deh(dration + =latelet aggregation + 20cessi-e pressure In cere ral -essels + )=C + .upture of lood -essels leaks to the rain + &ontralateral hemiparesis + Eeft side hemiplegic + Impaired ph(sical mo ilit(

ST!> After "%-F5 minutes of nursing inter-ention the patient should e a le to -er ali6e willingness to and demonstrate participation in acti-ities such as7 a. 2nerg(-conser-ing e0ercises. eg. .D: e0ercises. . &hanging of position e-er( two hours. c. 'houlder adduction. $T!> After 2-" da(s of nursing inter-ention the patient should e a le to maintain position of function and skin integrit( as e-idenced ( a sence of contractures! footdrop! and decu itus.

./> ;etermine diagnosis that contri utes to immo ilit( such as hemiplegia. > Cote decrease motor agilit( related to age. > ;etermine degree of immo ilit(. > :onitor -ital signs. T/> 2sta lish rapport. > Teach energ(-conser-ing e0ercises such as .D: e0ercises. > &hange patient3s position e-er( 2 hours > Teach patient a out shoulder adduction and position the patient properl(. > Teach patient in impro-ing mo ilit( and pre-enting ,oint deformities.

> To assess an( contri uting factor on patient3s progress. > To identif( causati-e@contri uting factors. > To assess functional a ilit(. > 'er-e as aseline data. > To gain trust from the patient and the significant others. > Eimits fatigue. > To reduce pressure and to pre-ent pressure ulcers. Also promote -enous return and pre-ent edema. > This helps pre-ent edema and the resultant ,oint fi rosis that will limit range of motion if the patient regains control of the arm. > &orrect positioning is important to pre-ent contracturesH measures are used to relie-e pressure! assist in maintaining good od( alignment! and pre-ent compressi-e neuropathies! especiall( of the ulnar and peroneal ner-es. > To elicit contri uting factor on patient3s disease. > 2nhances self-concept and sense of independence. > Eimits fatigue! ma0imi6ing participation. > =romotes well- eing and ma0imi6es energ( production.

ST!> Goal met. The patient was a le to -er ali6e willingness and demonstrate participation in acti-ities such as7 a. 2nerg(-conser-ing e0ercises. eg. .D: e0ercises. . &hanging of position e-er( two hours. c. 'houlder adduction.

$T!> Goal met. The patient maintains position of function and skin integrit( as e-idenced ( a sence of contractures! footdrop! and decu itus.

Ed/> Ad-ise patient to a-oid high fat and high salt diet. > 2ncourage di-ersional acti-ities such as sociali6ation. > 2ncourage significant others to do passi-e e0ercises to the patient. > 2ncourage ade*uate intake of fluids and nutritious foods.

Self7care deficit related to neuromuscular impairment. Assessment E/planation of the problem

!b5ecti2es

Nursing #nter2entions

*ationale

E2aluation

S> )aanak pa( nga maikuti da(to( kanigid nga imak kailangak ti tulong no mangan-ak ken no ag kutiak. !> Ceeds assistance when performing A;Es. > &an not mo-e his left hand and left leg. > )earing pro lem noted on the left ear. > 'peech impairment noted. > Appears weak. > &onscious and coherent. A> 'elf-care deficit related to neuromuscular impairment.

Arteriosclerosis + =la*ue formation + Carrowed lood -essels + Increase coagulation! decreased lood flow! h(potension! and deh(dration + =latelet aggregation + 20cessi-e pressure In cere ral -essels + )=C + .upture of lood -essels leaks to the rain + &ontralateral hemiparesis + Eeft side hemiplegic + Impaired ph(sical mo ilit( + 'elf-care deficit

ST!> After "%-F5 minutes of nursing inter-ention the patient should e a le to demonstrate techni*ues to meet self-care needs such as7 a. Impro-ing mo ilit( and pre-enting ,oint deformities. . 2arl( am ulation. $T!> After 2-" da(s of nursing inter-ention the patient should e a le to perform selfcare acti-ities within le-el of own a ilit(.

./> Cote concomitant medical pro lems that ma( e factors for care such as high /=! and altered cardinal signs. > Cote other etiological factors presentH including speech impairment and hearing pro lem. > Identif( degree of impairment. > :onitor -ital signs. T/> 1ill perform edside care such as stretching the linens and cleaning the surroundings. > Teach patient how to enhance selfcare. > Teach patient in impro-ing mo ilit( and pre-enting ,oint deformities.

> To identif( causati-e@contri uting factors. > To identif( causati-e@contri uting factors. > To assess degree of disa ilit(. > 'er-e as aseline data. > =ro-iding nonpharmacologic management and pro-iding comfort to the patient. > .eturn of functional a ilit( is important to the patient reco-ering after a stroke. > &orrect positioning is important to pre-ent contracturesH measures are used to relie-e pressure! assist in maintaining good od( alignment! and pre-ent compressi-e neuropathies! especiall( of the ulnar and peroneal ner-es. > =re-ents oredomH enhance coping a ilities. > 2arl( mo ilit( reduces complications of ed rest and promotes healing and normali6ation of organ function. > Eimits fatigue! ma0imi6ing participation. > :edications help relie-e the pro lem of the patient.

ST!> Goal met. The patient was a le to demonstrate techni*ues to meet self-care needs such as7 a. Impro-ing mo ilit( and pre-enting ,oint deformities. . 2arl( am ulation.

$T!> Goal met. =atient perform self-care acti-ities within le-el of own a ilit(.

Ed/> 2ncourage di-ersional acti-ities such as sociali6ation. > 2ncourage earl( am ulation. > 2ncourage 'D to do passi-e e0ercise to the patient. > Ad-ise patient to compl( with medication therap( as ordered ( the doctor.

#mpaired physical mobility related to pain secondary to surgical operation. Assessment E/planation of the problem !b5ecti2es Nursing inter2entions S> :asakit i(ong 'urgical operation ST!> After "%-F5 ./sugat ko kung <20-lap appendectom(8 minutes of nursing > Assess muscle strength. gugalaw ako. + inter-ention! the Tissue trauma patient will e a le to > Assess general status. !> Eimited range of + understand and

*ationale > ;etermine patient3s a ilit( to mo ili6e self. > 9now degree of immo ilit( in order to render appropriate nursing inter-ention.

E2aluation ST!> The goal was met ecause the patient was a le to understand and -er ali6e the ff. a8. Importance of earl(

motion. > 'lowed mo-ement. > =erform acti-ities of dail( li-ing with assistance. > 'urgical incision of appro0imatel( $-4 inches on um ilical to h(pogastric area. > Guarding of postsurgical area upon mo-ement. A> Impaired ph(sical mo ilit( related to pain secondar( to surgical operation.

.elease of neurotransmitters such as rad(kinin! histamine and prostaglandin + 'timulate ner-e impulse across the ner-e s(napse from the primar( afferent neuron to the dorsal horn + Transmission of signals to the thalamus + 'omatic sensor( corte0 of the rain + =erception and meaning + =ain is felt + Impaired ph(sical mo ilit(

-er ali6e a8. Importance of earl( am ulation. a.18 for good circulation a.28 to pre-ent adhesion of intestines. 8. =roper compliance to medication. .18 patient -er ali6e that he needs to take medications with the right the right dose at the right time. .28 a le to enumerate the importance of compl(ing to medications. $T!> After 2-" da(s of nursing inter-ention the patient will e a le to7 a8. ;emonstrate .D: e0ercise like fle0ion and e0tension of lower e0tremities. 8. :o ili6ation like walking from ed to &. and -ise -ersa! performing and repositioning self with or without assistance.

> ;etermine degree of immo ilit(. > Assess degree of pain. > Assess eha-ioral and emotional responses to pain. T/> Assist patient to reposition in ed.

> To pro-ide appropriate inter-entions and le-el of care to e render. > ;egree of pain contri utes to immo ilit(. > Cote factors affecting pain and coping that ma( impede goal attainment. > =re-ent the patient from e0erting too much effortH it also impro-es lood circulation that ma( aid in making the healing process faster. > :a0imi6e energ( and strength of the patient. > .estore strengthH impro-e lood circulation to aid in faster healing of incisionH a-oid cohesion of internal organs. > 20ercises like these can contri ute to rela0ation of muscle tension and relief pain and pro-ide comfort to the patient. > .educes fatigue. > 2nhance self concept and promote rest. > /e a le to render appropriate and effecti-e nursing care. > 2nhance self-concept and promotes independence. > =romote well- eing and ma0imi6e energ( productionH helps in faster wound healing and restore or replace lost od( nutrients. > .estore strength! impro-e lood circulationH aid in faster healing and pre-ent cohesion of microorganisms.

> Assist in performing acti-ities of dail( li-ing. > Assist patient to am ulate.

am ulation. a.18 for good circulation a.28 to pre-ent adhesion of intestines. 8. =roper compliance to medication. .18 patient -er ali6e that he needs to take medications with the right the right dose at the right time. .28 a le to enumerate the importance of compl(ing to medications. $T!> Goal was met ecause the patient was a le to7 a8. ;emonstrate .D: e0ercise like fle0ion and e0tension of lower e0tremities. 8. :o ili6ation like walking from ed to &. and -ise -ersa! performing and repositioning self with or without assistance.

> ;emonstrate deep reathing and range of motion e0ercises. > =ro-ide ade*uate hours of rest and sleep. > =ro-ide comfort ( stretching the linens. Ed/> 2ncourage patient to -er ali6e feelings and concerns > 2ncourage patient to participate in acti-ities as tolerated. > 2ncourage intake of fluid and nutritious foods especiall( foods rich in protein like fish! legumes! eans and meat. > 2ncourage patient to am ulate for at least 5-4 2F hours post operati-el(.

Acute pain related to tissue trauma secondary to surgical procedure. Assessment E/planation of the problem !b5ecti2es S> Casakit da(to( 'urgical operation ST!> After F5 sugat ko. <20cision iops(8 minutes to one hour > =atient rated pain + of nursing

Nursing inter2entions ./> Assess for the le-el of pain ( ranking scale <%-1%8! reports of pain! location!

*ationale > To e a le to render a more appropriate and effecti-e nursing care.

E2aluation ST!> Goal full( met. The patient was a le to -er ali6e her

as # out of 1%! 1% eing the highest. > =atient descri e pain as thro ing pain on the surgical site that is precipitated ( mo-ing and appl(ing pressure. !> An incision of appro0imatel( 1 inch from the right su mandi ular area. > Grimaces noted. > Guarding of the surgical site when in pain. >1ith intact! dr( and clean wound dressing. A> Acute pain related to tissue trauma secondar( to surgical procedure.

Tissue damage@ tissue trauma + .elease of chemical mediators such as rad(kinin which act as a neurotransmitter + 'timulate ner-e impulse across the ner-e s(napse from the primar( afferent neuron to the dorsal horn + Transmission of signals to the thalamus + 'omatic sensor( corte0 of the rain + =erception and meaning + =ain is felt

inter-entions and health teachings the patient will e a le to -er ali6e and demonstrate the following wa(s to relie-e pain7 a8. coughing and deep reathing e0ercises. 8. acti-e interaction with the people around him. c8. compliance to prescri ed pain medications. $T!> After 2da(s of nursing inter-entions! the patient will e a le to rate pain as 2" from the initial rate of # out of 1%.

*ualit(! and se-erit(. > Assess general health status. T/> 2sta lish rapport > .eposition on a semi-fowlers position <when indicated8. > ;emonstrate deep reathing and coughing e0ercises. > Administer prescri ed medication Ed/> 2ncourage the use of rela0ation techni*ues such as deep reathing e0ercises! listening to music and talking with significant others. > 2ncourage intake of fluid and nutritious foods especiall( foods rich in protein like fish! legumes! eans and meat. > Ad-ice to compl( with the prescriptions made ( the doctor.

> To determine other od( parts that ma( e affected ( the operation and to determine other a normalities. > To gain trust from the patient and the significant others. > :a( relie-e pain and enhance circulation. 'emi-fowlers position relie-es a dominal muscle tension. > =romotes rela0ation and relie-e pain. > )elps relie-e pain. > .elie-es muscle and a dominal tension! enhances sense of control! promotes rela0ation and impro-e coping a ilities. > =romote well- eing and ma0imi6e energ( productionH helps in faster wound healing and restore or replace lost od( nutrients. > =romote wellness and a-oid an( ad-erse effects that ma( e caused ( incompliance.

understanding of the importance of the following7 a8. coughing and deep reathing e0ercises. 8. acti-e interaction with the people around him. c8. compliance to prescri ed pain medications. $T!> Goal full( met. The patient was a le to rate pain as 2-" from the initial rate of # out of 1%.

#mpaired physical mobility related to pain secondary to surgical operation. Assessment E/planation of the problem !b5ecti2es Nursing inter2entions S> Casakit da(to( 'urgical operation ST!> After "%-F5 ./sugat ko no ag <20cision iops(8 minutes of nursing > Assess muscle strength. kutiak ken no + inter-ention! the agpapigsa-ak nga(. Tissue trauma patient will e a le to > Assess general status. + understand and !> Eimited range of .elease of neurotransmitters -er ali6e motion. such as rad(kinin! histamine a8. Importance of > ;etermine degree of immo ilit(. > 'lowed and prostaglandin earl( am ulation. mo-ement. + a.18 for good > Assess degree of pain. > =erform acti-ities 'timulate ner-e impulse circulation of dail( li-ing with across the ner-e s(napse a.28 to pre-ent > Assess eha-ioral and emotional assistance. from the primar( afferent adhesion of internal responses to pain. > 'urgical incision of neuron to the dorsal horn organs. T/appro0imatel( 1 inch + 8. =roper > Assist patient to reposition in ed. on right Transmission of signals to the compliance to su mandi ular area thalamus medication. of the neck. + .18 patient -er ali6e > Guarding of post'omatic sensor( corte0 of the that he needs to take > Assist in performing acti-ities of dail(

*ationale > ;etermine patient3s a ilit( to mo ili6e self. > 9now degree of immo ilit( in order to render appropriate nursing inter-ention. > To pro-ide appropriate inter-entions and le-el of care to e render. > ;egree of pain contri utes to immo ilit(. > Cote factors affecting pain and coping that ma( impede goal attainment. > =re-ent the patient from e0erting too much effortH it also impro-es lood circulation that ma( aid in making the healing process faster. > :a0imi6e energ( and strength of the patient.

E2aluation ST!> The goal was met ecause the patient was a le to understand and -er ali6e the ff. a8. Importance of earl( am ulation. a.18 for good circulation a.28 to pre-ent adhesion of internal organs. 8. =roper compliance to medication. .18 patient -er ali6e that he needs to take medications with the right the right dose at the right time. .28 a le to enumerate the importance of

surgical area upon mo-ement. A> Impaired ph(sical mo ilit( related to pain secondar( to surgical operation.

rain + =erception and meaning + =ain is felt + Impaired ph(sical mo ilit(

medications with the right the right dose at the right time. .28 a le to enumerate the importance of compl(ing to medications.

li-ing. > Assist patient to am ulate.

> ;emonstrate deep reathing and range of motion e0ercises. > =ro-ide ade*uate hours of rest and sleep. > =ro-ide comfort ( stretching the linens. Ed/> 2ncourage patient to -er ali6e feelings and concerns > 2ncourage patient to participate in acti-ities as tolerated. > 2ncourage intake of fluid and nutritious foods especiall( foods rich in protein like fish! legumes! eans and meat. > 2ncourage patient to am ulate for at least 5-4 2F hours post operati-el(.

> .estore strengthH impro-e lood circulation to aid in faster healing of incisionH a-oid cohesion of internal organs. > 20ercises like these can contri ute to rela0ation of muscle tension and relief pain and pro-ide comfort to the patient. > .educes fatigue. > 2nhance self concept and promote rest. > /e a le to render appropriate and effecti-e nursing care. > 2nhance self-concept and promotes independence. > =romote well- eing and ma0imi6e energ( productionH helps in faster wound healing and restore or replace lost od( nutrients. > .estore strength! impro-e lood circulationH aid in faster healing and pre-ent cohesion of microorganisms.

compl(ing to medications.

$T!> After 2-" da(s of nursing inter-ention the patient will e a le to7 a8. ;emonstrate .D: e0ercise like fle0ion and e0tension of lower e0tremities. 8. :o ili6ation like walking from ed to &. and -ise -ersa! performing and repositioning self with or without assistance.

$T!> Goal was met ecause the patient was a le to7 a8. ;emonstrate .D: e0ercise like fle0ion and e0tension of lower e0tremities. 8. :o ili6ation like walking from ed to &. and -ise -ersa! performing and repositioning self with or without assistance.

Acute pain related to tissue trauma secondary to surgical procedure. Assessment E/planation of the problem !b5ecti2es S> :asakit i(ong 'urgical operation ST!> After F5 sugat ko. <20-lap appendectom(8 minutes to one hour + of nursing > =atient rated pain Tissue damage@ tissue inter-entions and as # out of 1%! 1% trauma health teachings the eing the highest. + patient will e a le to > =atient descri e .elease of chemical -er ali6e and pain as thro ing mediators such as rad(kinin demonstrate the pain on the surgical which act as a following wa(s to site that is neurotransmitter relie-e pain7 precipitated ( + a8. coughing and mo-ing and appl(ing 'timulate ner-e impulse deep reathing pressure. across the ner-e s(napse e0ercises. from the primar( afferent 8. acti-e interaction !> An incision of neuron to the dorsal horn with the people

Nursing inter2entions ./> Assess for the le-el of pain ( ranking scale <o-1%8! reports of pain! location! *ualit(! and se-erit(. > Assess general health status. T/> 2sta lished rapport > .eposition on a semi-fowlers position <when indicated8. > ;emonstrate deep reathing and coughing e0ercises. > Administer prescri ed medication

*ationale > To e a le to render a more appropriate and effecti-e nursing care. > To determine other od( parts that ma( e affected ( the operation and to determine other a normalities. > To gain trust from the patient and the significant others. > :a( relie-e pain and enhance circulation. 'emi-fowlers position relie-es a dominal muscle tension. > =romotes rela0ation and relie-e pain. > )elps relie-e pain.

E2aluation ST!> Goal full( met. The patient was a le to -er ali6e her understanding of the importance of the following7 a8. coughing and deep reathing e0ercises. 8. acti-e interaction with the people around her. c8. compliance to prescri ed pain medications. $T!> Goal full( met. The

appro0imatel( $-4 + around her. Ed/patient was a le to rate inches from the left Transmission of signals to the c8. compliance to > 2ncourage the use of rela0ation > .elie-es muscle and a dominal pain as 2-" from the initial um ilical to the thalamus prescri ed pain techni*ues such as deep reathing tension! enhances sense of control! rate of # out of 1%. h(pogastric area. + medications. e0ercises! listening to music and talking promotes rela0ation and impro-e coping > Grimaces noted. 'omatic sensor( corte0 of the with significant others. a ilities. > Guarding of the rain $T!> After 2da(s of > Instruct patient to put pillow or folded > To lessen pain felt while doing &2 surgical site when in + nursing inter-entions! lanket on the surgical site when doing and pre-ent wound dehiscence. pain. =erception and meaning the patient will e coughing e0ercises. >1ith intact! dr( and + a le to rate pain as 2- > Ad-ice to compl( with the > =romote wellness and a-oid an( clean wound =ain is felt " from the initial rate prescriptions made ( the doctor. ad-erse effects that ma( e caused ( dressing. of # out of 1%. incompliance. yperthermia related to disturbances in the hypothalamic thermoregulating center of the brain secondary to illness ASSESSMENT PAT !P "S#!$!%" !&'E(T#)ES #NTE*)ENT#!NS *AT#!NA$E E)A$+AT#!N S, napudot ti agik ST!./ ST!Drganism enters the > :onitor and record -ital signs > ser-es as a aseline data !, fe rile! with a respirator( tract After 2 hours of nursing > assess general status > for further care and management. Goal full( met! the temperature of "#.2%& + inter-entions the patient3s T/ patient3s temperature > dr( mucous mem rane reaches the lungs temperature will decrease from > increase fluid intake to at least >To li*uef( secretions decreased from "4.B%& to % % > skin warm to touch + "4.B & to "4.5 & 1% glassless of water per da( "4.5%& > increased respirator( Goes to circulation > do Tepid 'ponge /ath > helps lower the od( temperature. rate7 "$ reaths per and loodstream > pro-ide rest periods > to facilitate comfort and rela0ation minute + and thus a-oiding fatigue > weak in appearance The indwelling organisms Ed/ > crackles heard upon multipl( > 2ncourage patient to increase > Ade*uate h(dration thins and auscultation on oth lung .elease of damaging oral fluid intake loosens pulmonar( secretions. fields. to0ins $T!> 2ncourage patient to eat > to gain energ( and to oost the $T!+ nutritious foods like fruits and immune s(stem. A, )(perthermia related /od( senses infection After 1 da( of nursing -egeta le! and to increase intake Goal full( met! the patient to distur ances in the + inter-entions of foods rich in -itamin &. was a le to demonstrate h(pothalamic Increased production of The patient will demonstrate thermoregulation thermoregulating center 1/& to com at infection thermoregulation as e-idenced e-idenced ( od( of the rain secondar( to + ( od( temperature within the temperature within the illness )(pothalamus makes normal range of "$.5%&-"4.5%& normal range of "$.5%&read,ustment of he set "4.5%& point to higher le-el + Increased heat production + fe-er

#neffecti2e air4ay clearance related to accumulation of secretions in the tracheobronchial tree Assessment E/planation of the !b5ecti2es Nursing inter2entions problem S> minsan nahihirapan ;ecreased lung ST!> ./akong huminga surfactant! After "%-F% minutes of nursing > Assess general health status. inter-entions the patient and !> &onscious and the significant others will e Infecti-e cough refle0 con-ersant a le to7 >Assess and monitor -ital signs diminishes tidal -olume >)as unproducti-e cough >assess reath sounds and >;ecreased reath a. -er ali6e understanding assess air mo-ement =oor al-eolar e0pansion. sounds on the right lung of cause and T/ field! upon auscultation. therapeutic > =osition on a fowlers position. Increases -iscosit( of the > 1eak in appearance. management regimen sputum . ;emonstrate eha-iors A> Ineffecti-e airwa( to impro-e or maintain Eeads to pooling of clearance related to clear airwa(. secretions in dependent accumulation of > ;emonstrate deep reathing areas. secretions in the and coughing e0ercises. tracheo ronchial tree $T! > &omplete airwa( After 1 da( of nursing > position head midline with o struction inter-entions the patient and fle0ion appropriate for age is followed ( a sorption the significant others would e Ed/of o0(gen from a le to7 > 2ncourage client to -er ali6e dependent al-eoli feelings. A. demonstrates eha-iors &ollapse of that portion of to impro-e or maintain clear the lung. airwa(. > Ad-ice to compl( with the prescriptions made ( the doctor. ;ecreased capacit( of the lungs to ring out > ad-ised to increase fluid intake irritation due to its collapse. >discourage to use of oil- ased products around the nose Ineffecti-e airwa( clearance due to accumulation of secretions

*ationale > To determine other od( parts that ma( e affected to determine other a normalities. > ser-es as the aseline data. > To ascertain status and note progress. > promotes lung e0pansion. It also takes ad-antage of gra-it( decreasing pressure on the diaphragm and enhancing drainage to different lung segments. > =romotes rela0ation! this also facilitates in ringing out of secretions. > to maintain open airwa( > =ro-ides opportunit( to the patient and significant others identif( and clarif( misconceptions and offer emotional support. > =romote wellness and a-oid an( ad-erse effects that ma( e caused ( incompliance. > fluids helps in li*uef(ing the secretions > To pre-ent aspiration to the lungs.

E2aluation ST!> Goal full( met. The patient and the significant others was a le to7 a. -er ali6e understanding of cause and therapeutic management regimen . ;emonstrate eha-iors to impro-e or maintain clear airwa(! such as ;/2 and &2. $T!> Goal full( met the patient and the significant others would e a le to7 A. demonstrates eha-iors to impro-e or maintain clear airwa(! such as ;/2 and &2.

#mpaired gas e/change related to alteration of o/ygen7carrying capacity of the blood Assessment E/planation of the !b5ecti2es Nursing inter2entions

*ationale

E2aluation

S> nahihirapan akong huminga. !> &onscious and con-ersant. >;ecreased reath sounds on the right lung field! upon auscultation. > 1eak in appearance. A> Impaired gas e0change related to alteration of o0(gencarr(ing capacit( of the lood

problem ;ecreased lung surfactant! Infecti-e cough refle0 diminishes tidal -olume =oor al-eolar e0pansion. Increases -iscosit( of the sputum Eeads to pooling of secretions in dependent areas. &omplete airwa( o struction is followed ( a sorption of o0(gen from dependent al-eoli &ollapse of that portion of the lung. ;ecreased capacit( of the lungs to ring out irritation due to its collapse. Impaired gas e0change related to alteration of o0(gen-carr(ing capacit( of the lood

ST!> After "%-F5 minutes of nursing inter-ention! the patient and the significant others will e a le to7 a. Knderstand and -er ali6e causati-e factors and appropriate inter-entions. . =articipate in treatment regimen within le-el of situation. .1. reathing e0ercises .2. coughing e0ercises $T!> After 1 da( of nursing inter-ention the patient and significant others would e a le to7 A. further participates in treatment regimen within le-el of situation. /.1. reathing e0ercises. /.2. coughing e0ercises. /.". proper positioning.

./> Assess general status. >Assess and monitor -ital signs >assess reath sounds and assess air mo-ement . T/> 2sta lish rapport > =osition on a fowlers position.

> To determine other od( parts that ma( e affected to determine other a normalities. > ser-es as the aseline data. > To ascertain status and note progress. > To gain trust from the patient and the significant others. > promotes lung e0pansion. It also takes ad-antage of gra-it( decreasing pressure on the diaphragm and enhancing drainage to different lung segments. > =romotes rela0ation! this also facilitates in ringing out of secretions. > to maintain open airwa( > =romote wellness and a-oid an( ad-erse effects that ma( e caused ( incompliance. > fluids helps in li*uef(ing the secretions > =ro-ides opportunit( to the patient and significant others identif( and clarif( misconceptions and offer emotional support. > To pre-ent aspiration to the lungs.

ST!> Goal met! the patient and the significant others had een a le to7 a. Knderstand and -er ali6e causati-e factors and appropriate inter-entions. . =articipate in treatment regimen within le-el of situation. .1. reathing e0ercises .2. coughing e0ercises $T!> Goal met! the patient and significant others had een a le to7 A. further participates in treatment regimen within le-el of situation. /.1. reathing e0ercises. /.2. coughing e0ercises. /.". proper positioning.

> ;emonstrate deep reathing and coughing e0ercises. > position head midline with fle0ion appropriate for age Ed/> Ad-ice to compl( with the prescriptions made ( the doctor. > ad-ised to increase fluid intake > 2ncourage client to -er ali6e feelings. >discourage to use of oil- ased products around the nose

yperthermia related to altered thermoregulatory process of the body. Assessment E/planation of the !b5ecti2es problem S> :ainit ang Al-eolar collapse ST!> After "%-F5 minutes of pakiramdam ko nursing inter-ention! the patient will e a le to7 .etain of lung !> &onscious and a. maintain core surfactants con-ersant. temperature within the

Nursing inter2entions ./> Assess general status > :onitor -ital signs <noting temperature ele-ation8.

*ationale > To e a le to render more appropriate and effecti-e nursing care. > >e-er of "4.#J& and a o-e

E2aluation ST!> Goal met! the patient was a le to7 a. maintain core temperature within the normal range of "$.5-

>;ecreased reath sounds on the right lung field! upon auscultation. > 1eak in appearance. >skin warm to touch. >fe rile with a temperature of "#%& >good skin turgor > Increased respirator( rate7 "5 reaths per minute. A> )(perthermia related to altered thermoregulator( process of the od(.

:icroorganisms thri-e in /od( senses the microorganisms /od( increases temperature.

normal range of "$.5"4.5%& . demonstrate eha-iors to monitor and promote normothermia. .1. tepid sponge aths .2. increase fluid intake .". ha-e a cool en-ironment. $T!> After " da(s of nursing inter-ention! the patient will e a le to7 a. e free of complications such as irre-ersi le rain damage. . :aintain a core temperature within the normal range of "$.5"4.5%& c. /e freer of sei6ure acti-ities.

T/> do Tepid 'ponge /aths >remo-e e0cess lankets and clothes. >administer paracetamol as per doctor3s orders. Ed/>;iscuss the importance of >luid intake. > 2ncourage client to increase intake of foods rich in calories

indicates infection or alteration of the od( processes... > T'/ will pro-ide a surface cooling. It also does! heat loss ( conduction and e-aporation. > heat loss ( conduction > paracetamol is oth an antip(retic and analgesic. > to a-oid deh(dration. >to meet increased meta olic needs.

"4.5%& . demonstrates eha-iors to monitor and promote normothermia. .1. tepid sponge aths .2. increase fluid intake .". ha-e a cool en-ironment. $T!> Goal met! the patient was a le to7 d. e free of complications such as irre-ersi le rain damage. e. :aintain a core temperature within the normal range of "$.5-"4.5%& f. /e free of sei6ure acti-ities.

#neffecti2e air4ay clearance related to accumulation of secretion on bronchial tree.

ASSESSMENT

E0P$ANAT#!N

%!A$S

N+*S#N% #NTE*)ENT#!NS

*AT#!NA$E

E)A$+AT#!N

'> Ada u(ek na ,a( a ( ko! tata lang met nga ada marekna na nga kasto( D> 1hee6es heard upon. auscultation. > 1ith producti-e cough characteri6ed as greenish! thick copious sputum. > <L8 nasal flaring. > <L8 orthopnea > ..M 2# cpm > In high fowlers position all of the time. > Kse accessor( muscles when reathing such as sternoclidomastiod > with o0(gen inhalation at 2 lmp A> Ineffecti-e airwa( clearance related to accumulation of secretion on ronchial tree.

=roduction of copious amounts of thick mucus. Impaired ciliar( action ;ecreased mucus clearance from airwa(s. Ineffecti-e airwa( clearance

'TD> after F hours of nursing inter-ention patient will e a le to maintain a patent airwa( ( demonstrating proper reathing e0ercise ETD> after 42 hours of nursing inter-ention! patient will a le to use the o0(gen ihalation intermittentl(.

;0 > Assess respirator( status noting rate and depth of respirations. > Asses characteristic of sputum such as color! amount! odor and consistenc(. > Auscultate reath sounds! noting ad-entitious sounds. > Assess mucous mem ranes and skin turgor. T0 > =lace in >owler3s or orthopneic position. > Assist with coughing and deep reathing at least e-er( 2 hours while awake. =osition seated upright! leaning forward during coughing. > Assist with @ or perform percussion and postural drainage as needed. > =ro-ide rest periods etween treatment and procedures. > =ro-ide supplemental o0(gen as needed. > Administer e0pectorant and ronchodilators as ordered. 2d0 > 2ncourage mo-ement and acti-it( tolerance. > Instruct to a-oid ronchial irritants such as cigarette smoke! e0tremes of weather and fumes. > 2ducate a out the effects of smoking > Instruct to co-er mouth when snee6ing and coughing > Instruct to use tissue G a paper ag to dispose

;0 > >re*uent assessment is -ital to monitor current status and response to treatment. > Aids in determining other possi le complications for occurrence of hemopt(sis or acterial infection. > Ad-entitious reath sounds decrease effecti-e inter-ention. ;iminished or a sent reath sound ma( indicate increasing airwa( o struction and possi le atelectasis. > ;eh(dration causes respirator( secretions to ecome thicker more tenacious and difficult to e0pectorate. T0 > upright positions impro-e -entilation and reduce the work of reathing. > The upright position promotes chest e0pansion increasing the effecti-eness of coughing and reducing the work in-ol-ed. > =ercussion helps loosen secretions in airwa(s! postural drainage facilitates mo-ements of these secretions out of respirator( tract. > Ade*uate rest is important to conser-e energ( and reduce fatigue. > 'upplemental o0(gen helps maintain ade*uate lood and tissue o0(genation. >using e0pectorants and ronchodilators increases the effecti-eness in clearing airwa(s. 2d0 >Acti-it( helps mo ili6e secretions and pre-ent them from pooling. > /ronchial irritants cause ronchoconstriction and increased mucus production! which then interferes with airwa( clearance. > for additional knowledge and reali6ation > .educes the spread of microorganisms > An important infection control measure reduces the spread of respirator( organisms to other people.

'TD > Goal met. /ecause patient was a le to do ;/2 and &2 ETD > Goal not met. /ecause patient had )A:A! thus luck of time and interaction.

#mpaired gas e/change related to carbon dio/ide retention secondary to respiratory acidosis.

ASSESSMENT

E0P$ANAT#!N

%!A$S

N+*S#N% #NTE*)ENT#!NS

*AT#!NA$E

E)A$+AT#!N

'> Cahihirapan akong huminga. D> ..7 2# cpm > <L8 of diaphoresis. > ;(spneic. > Irrita le. > .estless. > =ale skin. > Casal >laring. > &rackles heard. > A/G results7 p)7 4."F =a&D27 F# =D27 $B > =>T .esults7 'e-ere o structi-e! -entilator( d(sfunction with h(perinflation. A> Impaired gas e0change related to car on dio0ide retention secondar( to respirator( acidosis.

&D=; &ontinual ronchial irritation and inflammation Increased airflow resistance Al-eolar h(po-entilation Ina ilit( of lungs to e0crete car on dio0ide h(po0emia! d(spnea Impaired gas e0change

'TD> after # hours of nursing inter-entions patient will e0press feelings of comfort in maintaining air e0change as manifested (7 a.8 .eport a sence of d(spnea. .8 Impro-e respirator( rate from 2# N 2% cpm. c.8 A sence of nasal flaring. ETD> after 42 hours of nursing inter-entions patient will ha-e a normal gas e0change as manifested ( normal A/G le-els.

;0 > Assess and record pulmonar( status e-er( 2 hours. > :onitor -ital signs and heart rh(thm. > .ecord intake and output. > :onitor A/G le-els and notif( ph(sician for a normal findings. T0 > =lace in position that est facilitates chest e0pansion that est facilitates chest e0pansion. > &hange position e-er( 2 hours. > =erform acktapping! chest percussion and postural drainage. > Assist patient with A;E3s. 2d0 > Teach rela0ation techni*ues such as ;/2 and &2. > 2ncourage ade*uate rest.

> To pre-ent occurrence of h(po0emia. >To detect tach(cardia and tach(pnea this could indicate h(po0emia. > To monitor patient3s fluid status. > To detect h(po0emia and acid- ase im alance. > To enhance gas e0change. > To mo ili6e secretions and allow secretions and allow aeration of all lung fields. > To promote drainage and keep airwa( clear. > To decrease tissue o0(gen demand. > to promote airwar( clearance > to remo-e secretion and promote lung e0pansion > to promote comfort

'TD > Goal met. =atient e0pressed feeling of comfort in maintaining air e0change. ETD > Goal not met. /ecause patient had )A:A! thus luck of time and interaction.

#neffecti2e breathing pattern related to shortness of breath, mucus, and bronchoconstriction secondary to discomfort in breathing

ASSESSMENT '> )indi ako komporta leng huminga kasi ma( u o ako. D> <L8 'D/

E0P$ANAT#!N &ontinual ronchial irritation and inflamation Inflammation of the

%!A$S 'TD> after # hours of nursing inter-entions! patient will decreased the use of his accessor( muscle ETD> After 42 hours of

N+*S#N% #NTE*)ENT#!NS ;0 > Assess and record respirator (rate and depth e-er( 2 hours. > Auscultate reath sounds e-er( F hours.

*AT#!NA$E > To detect earl( signs of respirator( compromise. > To detect decreased and ad-entitious reath sounds.

E)A$+AT#!N > Goal met. =atient -er ali6ed comfort in reathing.

> .estless. > <L8 Casal >laring. > /arrel &hest. > &rackles heard upon auscultation. > &lu ing of nails. > &oughing noted with copious sputum. > ?iscous sputum production. > Kse of accessor( muscles for reathing. > with D2 inhalation running at 2 lmp A> Ineffecti-e reathing pattern related to shortness of reath! mucus! and ronchoconstriction secondar( to discomfort in reathing.

tracheo ronchial tree )(pertroph( and h(persecretion in go let cells and mucus glands. Increase sputum secretions. /ronchial congestion. /ronchoconstriction.

nursing inter-ention! patient will a le to manage d(spnea.

T0 > Assist to a comforta le position! such as ( supporting upper e0tremities with pillows pro-iding o-er ed ta le with a pillow to lean on and ele-ating head of the ed. > Administer o0(gen as ordered. > 'uction airwa(s as needed. > =erform chestph(sio-therap( to aid mo ili6ation and secretion remo-al. > =ro-ide rest periods @w reathing enhancement measures. 2d0> Teach patient a out7 - =ursed lip reathing

> These measure promotes comfort! chest e0pansion! and -entilation of asilar lung fields.

> Goal not met. =atient went home ecause of financial constraints. .ecommendation7 - continue to compl( with medication - to do the proper &2 and ;/2 - to ha-e ade*uate -entilation - ad-ise the mem er of the famil( not to smoke inside the house - a-oid polluted en-ironment.

> 'upplemental o0(gen helps reduce h(po0emia and relie-e respirator( distress. > To remo-e secretions. > =ercussion! -i ration! and postural drainage enhance airwa( clearance and respirator( effort. > To pre-ent occurrence of fatigue. > )elps maintain open airwa(s ( maintaining positi-e pressure longer during e0halation. > These measures allow patient to participate in maintaining health status and impro-e -entilation. > )elps minimi6e air trapping G fati*ue

Ineffecti-e reathing pattern.

- A dominal @ ;iaphragmatic reathing. - =erforming rela0ation techni*ues. - Taking prescri ed medications < ensuring accurac( of dose and fre*uentl( monitoring ad-erse effects.8