CUES AND NURSING SCIENTIFIC OBJECTIVES INTERVENTION RATIONALE EVALUATION

CLUES DIAGNOSIS RATIONALE

Altered Pain affects After 30 mins of

Subjective breathing individuals of At the end of 30 Independent appropriate
pattern related every age sex mins of nursing
“Sobrang sakit to pain and gender. It is appropriate ● Assess ● To intervention
hindi ko na kaya, secondary to the primary nursing and determin
parang ambigat possible reason people intervention the monitor e - Patient’s
bigat na sa metastasis to seek healthcare. patient should Vital changes pain
dibdib halos the lungs Unrelieved pain be able to: signs and scale
hindi na ako has the potential and O2 verify decrease
makahinga” as to affect every Decrease pain saturatio maintena d from
verbalized by system in the scale from 9/10 n nce of 9/10 to
the patient body and cause – 6/10 O2 7/10.
numerous saturatio
harmful effects. n and - Patient’s
If the respiratory breathing vital
Objective system is Maintain stable effective signs did
affected, vital signs ness not
Vital signs: decreased flows, become
volume, stable
BP: 160/90 atelectasis, ● Breathin right
shunting, ● Help g away
PR: 113 hypoxemia, pace exercises
cough and patient’s helps Throughout the
RR:26 infection may breathing promote hospital stay
be the specific pattern and - Respirati
T: 37.8 by doing
responses to maximize ons were
pain. (Bruner deep lung maintain
and Suddarth’s breathing expansio ed and
Chapter 12 pp. exercise. n and made
Pain scale 9/10
225-226) may help stable
decrease
(+) Restless perceptio - Adheren
n of pain ce and
(+) Nasal flaring complian
ce to
(+) Intercostal Throughout the ● Place ● Stress medicati
retraction hospital stay, the patient in increase on was
patient should a less s not
be able to: stressful perceptio evaluate
environm n of pain d due to
Lagging on the ● Maintain ent time
left hemi- normal constrain
diaphragm respiratio ts and
ns ● For discharg
Decreased left ● Position better e.
tactile fremitus ● Adhere client in lung
and semi- expansio
Smoker 6-7 comply fowler’s n
sticks x 30 years to the or hi-
treatment fowler’s
regimen

● Tracheos
● Prepare tomy
tracheost may be
omy set done if
at patient is
bedside unable to
breath
effectivel
y using
the nose
Dependent

● Administ
● Analgesi
er
cs are
 medicati given to
ons alleviate
(analgesi pain and
cs) as promote
prescribe better
d by the respiratio
doctor n

● Connect ● Oxygen
to supplem
oxygen entation
as fills in the
ordered needed
by the oxygen
physician in the
body