nursing diagnosis[1][1].finalgid niya

8/8/2019 Nursing Diagnosis[1][1].Finalgid Niya

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Nursing Diagnosis:

Ineffective airway clearance may be related to copious tracheobronchialsecretions and bronchospasm as manifested by:

a. Subjective: Nabudlayan ko mag ginhawa kung kis-a gani gasakit akondughan mag ubo.

b. Respiratory rate of 25 breaths/minute, labored, shallow, rapid,c. Persistent productive cough noted and expectorates to a copious, yellow

to greenish, blood streaked sputum approximately 2-3 cc perexpectoration

d. Dyspnea after prolonged conversatione. Decreased tactile fremitus at lower lobe of the left lung.f. Asymmetrical chest expansion with left chest slightly higher upon

inspiration

g. Dullness heard upon percussion of the posterior left lungh. Crackles heard over the right lung and pleural friction rub on the left lungi. Pneumonia, left lung with right consolidation as shown in the X-ray results

last September 1, 2005.

Definition:

Inability to clear secretions or obstructions from the respiratory tract tomaintain a clear airway

Goals of Care:

a. Within 8 hours of nursing and medical interventions, patient will be ableto maintain a patent airway.

b. Within 30 minutes to 1 hour of medical and nursing interventions, patientwill be able to clear airways through effective expectoration of secretion.c. Within 1 hour of nursing interventions, patient will effectively perform and

participate in deep breathing exercises.d. Within 1-2 hours of medical and nursing intervention, patient will

verbalize relief of dyspnea as exhibited by ability to withstand prolongedconversation.

e. Within 8 hours of medical and nursing intervention, patient will manifestsa decrease in abnormal breath sounds.

INTERVENTIONS RATIONALE

NURSING

Assessment/Diagnostic:

1. Monitor respiratory rate,

rhythm, depth, and chestmovements.

2. Assess ability to expectoratesecretions effectively andassess the characteristics,

quantity, color, consistency,and odor of sputum.

3. Auscultate lungs for crackles,pleural friction rub, wheezes,and decreased airflow.

4. Routinely check the patientsposition.

Abnormalities may indicate difficulty

of breathing and respiratory distress

To determine if patient canexpectorate secretion effectively andto note for the severity of infection

Determines the adequacy of gasexchange and extent of airwaysobstructed with secretions

To maintain position that promotesmaximum lung expansion

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Treatment/Therapeutic:

1. Assist patient with coughingand deep breathing exercises

at least 10 times every hourwhile awake.

2. Position patient in semi to highfowlers

3. Perform chest physiotherapysuch as percussion and

vibration.

4. Assist patient with oral hygieneevery after Pulmo-aidinhalation or as needed

5. Provide fluids (water)

6. Perform hand washing beforeand after contact with patientor care.

7. Provide sputum receptacle and

tissue by bedside.

8. Limit verbal interaction or

discussion toimportant/significant topics orissues.

9. Encourage rest duringexacerbation of cough or

dyspnea.

Health Teachings:

1. Encourage patient to increasefluid intake to 1.5 to 2 liters

per day.

2. Instruct and demonstrateproper hand washing.

3. Teach patient the importanceof deep breathing andcoughing exercises and

demonstrate the proper way toperform.

Coughing removes secretions toprevent atelectasis. Deep breathing

exercises facilitate maximumexpansion of the lungs or the smaller

airways.

Secretions move by gravity asposition changes. Elevating head of

bed moves abdominal contents awayfrom diaphragm to enhance

diaphragmatic contraction andrelieves dyspnea.

Applying percussion and vibration tochest loosens secretions so that itcan be expectorated.

Removes taste of secretions and

prevents irritation of the oral mucosaafter Pulmo-aid inhalation.

To liquefy secretion for easyexpectoration

To prevent spread of infection

To prevent contamination and forproper disposal of infectious materials

To lessen oxygen consumption, thuspreventing occurrence of dyspnea.

To lessen pain perceive every timepatient experiences cough and

dyspnea.

Liquefies secretions so that they areeasier to expectorate

To prevent contamination, cross

infection and maintain cleanliness

Provide information, aid in lung

expansion, airway clearance andeasily expectorate secretions

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4. Encourage patient to ambulatewhen tolerated and change

position at least every 2 hours.

5. Teach patient to splint chestwhen coughing.

6. Instruct patient to cover mouthwhen coughing.

7. Teach patient and familymembers/visitors good hand

washing technique.

8. Instruct family members,

significant others and visitorsto limit prolonged conversationor discussion with patient.

COLLABORATIVE

Assessment/ Diagnostics:

1. Monitor chest x-ray results.

2. Monitor sputum gram stain and

culture and sensitivity reports.

Treatments/Therapeutic:

1. Administer Pulmo-AideInhalation with Salbutamol 1

nebule every 6 hours asordered.

2. Administer acetylcysteine

(Fluimucil) 600 mg/tab 1 tablet

dissolved in glass water asordered.

3. Provide humidified oxygen asneeded.

Health Teachings:

1. Inform patient and significant

others of the possible sideeffects of medications such as:

a. Salbutamol- headache ,tremors, tachycardia

and palpitationsb. Fluimucil-

nausea/vomiting,urticaria, bronchospasm

Secretions are moved by gravity asposition changes and duringambulation.

To lessen discomfort and pain


To prevent cross contamination

between patient and significantothers

To provide adequate rest to patient

and prevent the occurrence of

dyspneic episodes and chest pain

Shows extent and location of lung

involvement

Identifies microorganisms present sothat appropriate anti-infective agents

can be prescribed

Aids in reduction of bronchospasmsand dilation of bronchial smooth

muscles

Decrease mucus viscosity by breaking

or altering chemical bonds orglycoprotein complexes.

To prevent drying of secretions andlung ventilation

To provide patient and significant

others information of what to expectafter taking the medications

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Evaluation:

After 30 minutes of medical and nursing intervention,Patient was able to effectively expectorate secretion (copious, yellow to

greenish, blood streaked sputum approximately 2-3cc per expectoration).Patient verbalized relieved of dyspnea even after conversation.

Patient was able to perform splinting activity, covers mouth when coughing,dispose used tissue appropriately in a receptacle.

After 8 hours of medical and nursing intervention,

Patient was able to maintain a patent airway.Patient, family members and visitors demonstrate proper hand washing

techniques.Patient demonstrates effective deep breathing and coughing technique

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Nursing Diagnosis:

Disturbed Sleeping Pattern maybe related to persistent coughing at night asevidenced by:

a. Subjective cues: Kulang gid akon tulog kay sige-sige akon ubo kung

gab-i siguro mga tatlo lang asta lima kaoras akon tulog, kis-a ganigasakit na akon dughan ka-ubo.

Definition:

Time-limited disruption of sleep (natural, periodic suspension ofconsciousness) amount and quality.

Goals of Care:

Within 8 hours of nursing and medical interventions, the patient will sleep for1-2 hours after lunch.

Within 24-48 hours of medical and nursing interventions, the patient will beable to:

a. Report improvement in sleep, 6-8 hours at night

b. Report increase in sense in well-being and feeling rested during the dayc. Identify individually the appropriate interventions to promote sleep at

night

d. Participate actively in activities planned for him during the day.


NURSING


1. Assess for factors thatcontribute to sleep pattern

disturbances other thanpresence of persistent cough;

routine nursing care; noise;pain/ discomfort.

2. Observe and obtain feedbackfrom patient or significantothers regarding usual

bedtime, rituals, routines,number of hours of sleep, time

of arising and environmentalneeds.

3. Monitor hours of continuoussleep at night or during theday and time of arising.

4. Observe for signs of fatigue,restlessness, irritability, andpoor compliance to activitiesplanned for patient such asvital signs taking, treatments,

and administration ofmedications.

To control factors that may contributeto inadequate hours of sleep

To determine usual sleep pattern andprovide comparative data

To plan and evaluate appropriateinterventions, which patient couldtolerate and determine usual sleeppattern to provide comparative

baseline

To plan schedule of activities to

provide rest periods for the patient

To provide an environment conducive

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5. Note environmental facilitiesthat may affect the sleepingpattern of the patient such asair conditioning unit, electric

fans, lights, and curtains.

6. Listen to patients report ofsleep quality.


1. Provide a quiet environment

such as closing the door andminimize getting in and out of

the room.

2. Provide a dim environment for

sleep time.

3. Provide comfort measures such

as backrub, washing of handsand face, bathing, oral

hygiene, cleaning and fixinglinens in preparations for

sleep.

4. Let patient assume position ofcomfort without compromising

body alignment.

5. Schedule patients program of

activities and routine nursingcare with rest periods

6. Adjust air conditionthermostat to keep room cool

or provide electric fan forpatient as needed.

7. Provide extra blanket by

bedside during nighttime sleepin case patient feels cold orchilly, or change afterperspiring or diaphoretic

episode. (linens included)

8. Close door if patient prefersduring rest or sleep time.

9. Post a sign on closed door, ifpatient is resting or asleep.

- Limit or screen visitors.

- Knock softly on doorbefore opening and

entering room.- Post a sign that says:

for rest

To know what the patient really

feels toward the problem

A quiet environment promotes sleepand relaxation

To promote sleep and relaxation

To promote sleep and relaxation

To promote relaxation and comfortduring sleep, to promote circulation,adequate tissue perfusion

That patient will be able to performactivities at his optimum level. Limit

fatigue and exhaustion in activities ofdaily living performance

Provide an environment conducive forsleep.

Provide a comfortable sleep forpatient.

To minimize disturbances such as

noise and visitors from going in andout of the room

To allow only those visits that arevery important so that patient willhave longer time for resting. To

screen visitors and provide healthteachings such as washing of hands

before and after

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Check with nurse onthe station beforeentering room

Health Teachings:

1. Encourage and stress theimportance of participation in

regular exercise programduring the day, such as deepbreathing and coughingexercises and other active and

passive range of motionexercises as tolerated.

2. Inform patient that foods and

drinks high in caffeine such as

tea, coffee, cola drinks, andchocolates may interfere withsleep.

3. Encourage to nap after lunch.

4. Instruct patient not to engagein strenuous activities such asweight bearing before sleepingtime.

5. Instruct patient to have extra

clothing by bedside or shirts tochange when perspiring or

wet.

COLLABORATIVE:Assessment:

1. Note for side effects ofmedications (Fluimuci)l such as

nausea/vomiting, urticaria an

bronchospasm, that couldcause sleep disturbance.

Treatment:

1. Reportpersistence of sleeplessnessafter performing applicableindependent interventions

Health Teachings:

1. Encourage patient to verbalizeside effects of medicationsexperienced that alter sleepsuch as exacerbation of coughat night may be due to

Fluimucil, a mucolytic, which istaken at bedtime.

Aid in stress control or release of

energy because exercise in lateafternoon or in the evening may

stimulate rather than relax the clientand may even interfere with sleep

For patient to prevent intake ofcaffeine rich foods and drinks that

could interfere with sleeping pattern

To the regain the energy from lack ofsleep during the night

Being energized before bedtime

would bring about difficulty of sleep

For comfort measures

To inform physician of side effectspresent on the patient that could

alter sleep.

For physician to do appropriateinterventions regarding patients

continued inability to sleep

To inform physician of the sleepdisturbance caused by themedications

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2. Stress the importance ofcompliance to medications and

treatments

3. Explain the importance ofcompliance of avoidingbeverages with caffeine.

4. Encourage reading and musictherapy before afternoon nap

or nighttime sleep.

To encourage patient to takemedications strictly that helps lessensymptoms of disease that alter sleep

Caffeine is a stimulant

Reading and listening to music couldpromote sleepiness

Evaluation:

After 24-48 hours of nursing and medical interventions, patient verbalizedthat, he had approximately 6-8 hours of sleep after the relief of symptoms of thedisease such as cough and chest pain.

He stated that he had decreased physical exhaustion during the day.

The patient and significant others expressed performance of sponge bathingand turning off lights before sleep.

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Nursing Diagnosis:

Chronic pain may be related to persistent coughing as manifested by:

a. Subjective: Nabudlayan ko mag ginhawa kung kis-a gain gasakit akondughan mag ubo.

b. Verbalized chest pain felt rated as 6 in a scale of 0-10 (0 for no pain and 10as to excruciating pain) gradually decreasing after coughing lasting 2 to 3

minutes, aggravated by return of coughing and prolonged conversation

c. Facial grimace and muscle guarding as claimed

Acute pain as manifested by:a.Burning pain on the IV site rated as 3 in the scale of 0-10,

aggravated by moving, alleviated by immobilization.b. Grade 1, non-pitting edema noted at IV site.

Definition:

Unpleasant sensory and emotional experience arising from actual or potential

tissue damage of described in terms of such damage; slow onset of any intensityfrom mild to severe, constant or recurring without an anticipated or predictable endand a duration of more than six months, or duration of the disease.

Goals of Care:

a. Within 1-2 hours of medical and nursing interventions, patient will be able toreport decrease of pain when coughing from a scale of 6 to a scale of 4 in

McGills Scale of Pain, 0 as to no pain and 10 as to excruciating pain.b. Within 1-2 hours of medical and nursing interventions, patient will

demonstrate use of relaxation skills and diversional activities such as chestsplinting, deep breathing exercises, reading and listening to the radio or

watching television.c. Within 4 hours of nursing and medical interventions, patient will perform

routine activities of daily living such as transferring, ambulating, bathing,grooming and hygiene, toileting with minimal set-up or 1 person assist.

d. Within 1-2 of nursing and medical interventions, patient will verbalize reliefof pain in the IV site.

e. Within 1-2 hours of nursing and medical interventions, patient will manifestdecrease size of edema on the IV site.


NURSING:


1. Determine pain characteristics;investigate changes in the

character, location, andintensity of pain using theMcGills scale.

2. Continually monitor vital signsevery 4 hours.

3. Identify aggravating factors forpain.

4. Assess for characteristics ofpain on the IV site.

To know the severity of pain felt thusbe able to give appropriate nursing

interventions

Any alterations in the vital signs mayindicate presence of pain.

To be able to control these factorsand to know what kind of interventionwill be given

To know the severity of pain felt thusbe able to give appropriate

interventions

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5. Note for the presence ofedema on IV site


1. Provide comfort measures suchas backrubs, relaxation, and

deep breathing exercises.

2. Assist patient to assumeposition of comfort such as

elevation of the head of thebed, sit on edge of bed, and

assume orthopneic position.

3. Provide diversional activitiesappropriate for age and

condition such listening toradio, watching TV, reading

4. Provide set-up or assist with

routine activities of daily livingsuch as transfer from bed tochair, ambulate, toileting,hygiene, bathing, grooming.

5. Keep patients back dry. Pat

dry and change shirt asneeded.

6. Provide warm compress on

knee every time there is pain

7. Elevate left forearm and applywarm compress.

Health Teachings:

1. Encourage patient to report

pain.

2. Instruct and assist patient inusing pillow to splint chest

during coughing episodes.

COLLABORATIVE:Therapeutic

1. Refer accordingly forpersistence of pain if notrelieved by non-

pharmacological measures.

To know if the IV line is patent

Non-pharmacological measures helpalleviate pain. It refocuses attention,

promotes relaxation, and enhancessense of control, which may reducepharmacological dependency.

To promote maximum lung expansionand comfort that lessens pain.

Helps lessen concentration on painexperience and refocus

To minimize exertion of much effort

in doing such activities of daily livingso as to lessen pain perception

To promote comfort

To alleviate pain perceived.

To reduce edema, facilitating venousreturn

So that proper interventions can be

done

To lessen pain and promote comfort

Provides baseline data, which can be

use for treatment regimen.

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Evaluation:

At the end of 2 hours of medical and nursing interventions, patient verbalizeda decrease in pain from a rating of 5 to 3 with splinting upon coughing.

He shows a relaxed manner, resting, sleeping, and engaging in activities

such as feeding himself, performing oral care, and ambulating with one-personassist.

Edema on IV site not noted.

Patient engages in activities such as reading, listening to music on the radioand watching television.

Vital signs are within patients normal range.

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Nursing Diagnosis

Altered nutrition: less than body requirements may be related to discomfortassociated with coughing and dyspnea as manifested by:

a. Subjective cues: Nagniwang gid ko ya. Halin sa 49.6 kilos sang sinelang nga Agosto 29, 45 kilos na lang akon timbang subong.

b. Subjective cues: Indi gid manamit ang sud-an sa hospital.c. Subjective: Di ko gawa ka panimaho kung lain matyag ko.d. Subjective: Indi mayo ang panabor ko sa pagkaon kay gina ubo akoe. Consume 45% of the meal served in the hospital.

f. With poor smelling acuity on both nares upon testing with the useorange peelings and bath soap

g. With decreased ability to differentiate, taste of sugar and coffee upon

testing.

Definition:

Intake of nutrients is insufficient to meet metabolic needs.

Goals of Care:

a. Within 2 hours of medical and nursing intervention, patient will verbalizefood choices or preferences.

b. Within 2-3 days of medical and nursing interventions, patient will manifestincrease in appetite by consuming approximately 60-75% of meals

served.c. Within a week of nursing interventions, patient will be able to gain at least

2 kilos approximately.

Inadequate tissue perfusion maybe related to decrease in hemoglobin and

hematocrit count as evidenced by:

a. slightly pale conjunctiva, palm of the hands and nailbedsb. poor capillary refill of 3 seconds upon blanching test

c. hemoglobin count of 11.6 g/dL (Sept. 1, 2005)d. hematocrit count of 34.7% (Sept. 1,2005)

Definition:

Decrease in oxygen resulting in the failure to nourish the tissues at thecapillary level.

Goals of Care:

1. Within 8 hours of nursing intervention/treatment, patient will exhibitadequate perfusion as evidenced by:

a. Blood pressure within patients normal range 110/70-120/80 mmHg.

b. Heart rate strong and regular


13/30


NURSINGAssessment/Diagnostic

1. Assess patients food choices orpreferences.

2. Determine other factors, whichcontribute to patients poor

appetite such as coughing,expectoration, incomplete set

of teeth and presence ofdentures.

3. Assess hydration status:a. check skin turgorb. check fluid intake

4. Auscultate for bowel sounds.

5. Assess patients last bowelmovement.

6. Assess patients weight

continually.

7. Assess peripheral perfusion

status for skin color, skintemperature, quality of pulses

and capillary refill.

8. Assess patients level ofconsciousness, orientation to

time, person, place, andevents.

9. Continuously monitor vitalsigns especially blood pressureevery 4 hours; assess fordizziness.

10. Observe for restlessness,

confusion, change in level ofconsciousness or mental status.

11. Watch out for presence of chestpain and irregular heart rate.

To know if patients food preferenceis nutritional or not and to find outwhat foods will stimulate his appetite

To control factors that could alter ordecrease desire to eat.

To determine if patient isdehydrated.

Document GI peristalsis needed for

digestion.

Unable to defecate decreasesappetite. (one of the side effects that

patient may experience while takingPropan with Iron is constipation)

This will serve as a baseline data and

for evaluation of nutritional status inrelation to food intake.

Cool skin temperature, pallor,

decreased motor or sensory functionand venous engorgement

(prominence) in lower extremitiesare signs of inadequate peripheral

perfusion.

Alteration in the level ofconsciousness may be due to

decreased oxygenation in the brain

To obtain baseline data and assess

the status of the patient; Dizzinessmight indicate orthostatic

hypotension.

These factors indicate inadequate

oxygenation in the brain

This may indicate inadequate oxygensupply to major organs in the body

such as the heart

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12. Monitor CBC results(especially Hgb and Hct levels).

Treatment/Therapeutic

1. Provide small frequent mealsfoods that are appealing to the

patient.

2. Provide or assist with oralhygiene after Pulmo-Aide

Inhalation.

3. Maintain a clean environment.Remove noxious stimuli such as

bedpan, urinal, and trash can.Dispose used tissues in sputum

receptacle before mealtime.

4. Assist with proper handwashing before and aftermealtime.

5. Serve food according to diet

ordered for the patient. (DietAs Tolerated)

6. Assist with oral hygiene anddenture care as needed.

7. Acknowledge every timepatient is able to consume

food.

8. Instruct patient and family tokeep skin moisturized with

lotion.

9. If hypotension is present, stopactivity, assist patient to sit orassist back to bed, placepatient in supine position.

10. If hypotension is present:instruct to change position

slowly in bed, provideassistance with routine ADLcare as in positioning, transfer,toileting, grooming andhygiene; keep side rails up for

safety, bed mobility, positioningand transfers.

An alteration in this laboratoryresults may indicate decreasedamount of circulating red blood cellsthat are responsible for supplying

oxygen to different parts of thebody.

Stimulate appetite but requires lessenergy thereby reducing oxygenrequirement.

Stimulates good appetite; Prevents

the risk for fungal infection.

Unclean environment or offensiveodors decrease patients appetite toeat.

Reduce microorganisms present in

the hands of the patient

To meet the specific metabolic need

of the patient.

Promote hygiene and develop

independence; Removes sputum andfood particles in the mouth and

dentures.

To motivate patient to eat more

Patient has dry skin so to moisturizethe skin.

To relieve hypotension

To prevent occurrence of orthostatic

hypotension

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Health Teachings:

1. Instruct patient to get out ofbed and sit in chair during

mealtime.

2. Instruct patient to perform oralcare such as brushing the floorof the tongue and cleaning of

dentures before and aftermeals.

3. Inform patient that eating a

balance diet each day isimportant in maintaining the

immune system.

4. Encourage patient to consumeapproximately 60-75% of

meals served.

5. Advise patient to take food anddrinks rich in:

Vitamin C such as citrusfruits or drinks an orange

juice.

Folic acid such as greenleafy vegetables (iron

rich foods like liver andother organ meats)

Protein rich foods such

as meat, milk and fish

Vitamin B6 such as liver

and organ meats

Carbohydrates such asrice, corn and bread

Vitamin A such as cheeseand carrots

High fiber foods such as

ripe papaya and greenleafy vegetables

6. Instruct patient to takemedications with food

7. Instruct patient to avoid

activities that requires mentalalertness

To facilitate passage of food andeasy digestion; avoid aspiration

For proper hygiene and to diminishthe bad taste of phlegm; removefood particles

Increase patients awareness ofproper eating habits.

To increase patients food intake

Vitamin C rich foods increase theabsorption of iron and enhance

immunity.

It aids in protein metabolism

They repair and maintain bodytissues

Isoniazid decreases pyridoxine in thestomach

They are the bodys major source of

energy and utilize other nutrientsTo improve eyesight

To prevent constipation brought

about by medications

To avoid GI irritation

To avoid accidents due to drowsiness

effect of medications

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COLLABORATIVE:Assessment:

1. Evaluate Chemistry report for

electrolyte levels in the blood.

2. Instruct on the side effects ofPropan with Iron

Treatments/Therapeutic:

1. Give vitamins as ordered:

a. Centrum 1 tablet once aday

2. Provide supplementalintravenous fluids as ordered.

3. Administer Propan with Iron 1capsule once a day at 8 pm

Health Teachings:

1. Encourage wife to bring favorite

foods of the patient such as

Tinolang manok

2. Inform patient and significant

others of the side effects ofmedications and to watch outand report for adversereactions:

a. Centum- GI upset andirritation

b. Propan- mild drowsinessand GI discomfort

Evaluate fluid and electrolyteimbalance especially Sodium

Know that Propan with Iron causes

black-colored stool and constipation.

To serve as a multi-vitaminsupplement

To avoid dehydration due to

insensible loss of fluids

Stimulates appetite and serves as an

iron replacement; aids in theproduction of red blood cells

To stimulate appetite

To provide information and

awareness of the possible effects ofmedications

Evaluation:

After 1 hours of nursing and medical intervention, patient was able toverbalize food choices and preferences.

After 3 days of nursing and medical intervention, patient is able to consumemore than or equal to 75% of the meals served in the hospital.

Patient increased his fluid intake to 2 liters per day. He was able to consumefoods from home and perform good oral hygiene and denture care.

After 2 hours of nursing and medical interventions, patient was able to

verbalize food choices, preferences, and sits up in chair for meals.

At the end of 4 hours of nursing intervention, patient exhibited strong,palpable peripheral pulses +2, strong, regular heart rate, synchronous with left

radial pulse rate of 82 beats per minute.

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No significant changes in level of consciousness or mental status, patient isalert, oriented to time, place, persons and events, with capillary refill of 2 seconds,

skin is warm and moist to touch.

At the end of 2 days of nursing interventions/treatment, patient exhibitedpinkish bilateral conjunctiva, palms of hands and nail beds.

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NURSING DIAGNOSIS:

Social Isolation may be related to altered state of wellness secondary topersistence of uncontrolled cough as evidenced by:

a. Subjective: Nahuya na ko mag atubang sa mga taw okay gaubo ako

permi.

Definition:

Aloneness experienced by the individual and perceived as imposed bydisease condition and as a negative or threatened state.

Goals of Care:

Within 1 hour of medical and nursing interventions, the patient will be able to

interact verbally with nurses, medical staff, or other persons, significant others,

visitors with no breathing difficulty (coughing, dyspnea) or exhaustion.Within 1-2 hours of medical and nursing interventions, the patient will be

able to express increased in self-worth such as smiling and interaction.



1. Assess patients feelings about

self, disease condition, senseof ability to control situation,

sense of hope and copingskills.

2. Assess factors that maycontribute to isolation such aspatients health status

(persistent cough).

3. Identify support systemsavailable to patient such as

presence significant others.

Treatment/ Therapeutic

1. Talk to patient about topicsthat may interest him.

2. Provide positive reinforcement

when client initiatesconversation with others

(visitors, health team).

3. Promote participation in special

interest activities such ashaving conversations withhealth team, visitors and

significant others.

4. Continue to screen or limitvisitors of patient.

Serve as a basis for determining

appropriate interventions to be given.

To control factors that may increasepatients feelings of being isolatedfrom others.

When patient has assistance fromsignificant others, feelings of shyness

are diminished

To promote verbal interaction,diminishing feeling of shyness

Encourage continuation of efforts

To promote socialization skills and

interpersonal contact

To afford the patient rest, limit therisk of spread of infection.

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5. Schedule rest periods inbetween social or routinehealth related activities (suchas vital signs taking, bathing,

and meals).

Health Teachings

1. Encourage patient to ambulateout of room in hallway withassistance or supervision.

2. Encourage patient and

significant others to converseand interact with each other.

3. Encourage family members to

use touch when interactingwith patient.

4. Instruct to choose and pace

conversations or verbalinteractions appropriately.

5. Instruct to cover mouth whencoughing.

6. Instruct patient to bring with

him disposable tissue paperand dispose properly after usein sputum receptacle.

7. Encourage family or significantothers to provide praise forattempted or accomplished

tasks.

To allow patient to rest and gainenough strength to accomplish otherhealth related or social tasks

To meet and interact with differentpeople and health staff or team

Helps reestablish a feeling ofparticipation in a social relationship.

To reduce sense of isolation and

promote healthy socialization

So as not to feel exhausted or triggercough episodes

To prevent cross infection

To prevent cross infection

To develop self-esteem and increaseself-worth

Evaluation:

After 2 hours of nursing and medical interventions, patient was able to:

Ambulate with 1 person assist out of room.Interacted for 10 minutes with another patient and the health team,

conversed with family and significant others.Family members especially wife uses touch therapy when verbally interacting

with patient.Patient smiles, maintains eyes contact when talking about topics of interest.

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Nursing Diagnosis:

Knowledge deficit regarding disease condition, treatment needs, anddischarge needs may be related to lack of information about the disease asevidenced by:

a. Subjective cues: Gapacheck up ko pero wala ko kabalo kung anusakit ko kay wala ya man ginhambal sa akonbasta ginaresitahan langkoanong pulmonya day haw?

Definition:

Absence of cognitive information related to specific topics (mentioned above)

Goals of Care:

a. Within 2 hours of medical and nursing interventions, patient will be

able to explain the disease condition, treatment, and discharge needs.b. Within 2 hours of medical and nursing interventions, patient will be

able to enumerate the importance of compliance to drug regimen,medical and nursing treatments and health teachings.


NURSING:Assessment/Diagnostic:

1. Determine impediments or

obstacles to learning such as

low educational attainment,hearing problem and use ofadaptive device such aseyeglasses.

2. Assess the patient if he canhear and understand what is

being spoken.

3. Ask patient some questionsabout Pneumonia andTuberculosis.

4. Identify signs/symptomsrequiring notification of

healthcare provider such asincreasing dyspnea, chest pain,

prolonged fatigue, weight loss,fever and chills, continuousproductive cough and changesin mentation.

5. Assess patients interest and

attention span for interactionand education.


1. Organize content about

Pneumonia.

To serve as basis for choosing

appropriate topics, terminologies and

approach in educating the patientabout the disease

To establish good communication

To determine what information aboutthe disease still needs to bediscussed

Prompt evaluation and timelyintervention may prevent or minimize

complications

To identify a need to reschedule

activity and simplify explanation asneeded.

For the patient to easily understand

what is being explained by the nurseand to avoid missing important

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2. Choose appropriate time andcondition of the patient in

providing information related toPneumonia.

3. Establish rapport by introducing

self, maintaining eye contact,smiling, and approachingpatient in a calm manner;explain to patient and the

purpose of visit or interaction.

4. Speak directly facing the

patient. Use well modulated

tone of voice.

5. Give information on patients

right ear.

6. Use terms or statement that issimple for patient tounderstand according tointellectual or educational level.

7. Ask questions after giving

health teachings andinstructions.

8. Provide information about the

importance of medications,treatments, and healthteachings in written and verbalform.

9. Ask patient to repeat or clarify

information provided, asneeded.

Health Teachings:

1. Discuss in simple terms the

normal functioning of the lungs,how it is related to Pneumonia

and its contributing factors.

2. Explain to the patient and thesignificant others the nature ofthe disease such as its

communicability, and itscomplications

3. Stress importance of continuing

deep breathing and effective

details

Patient could listen effectively on thetime and condition he is most

comfortable

To establish good communication

between the nurse and patient; toprovide basic knowledge of thepurpose of the visitation and todeliver information clearly

To get the patients attention and

that he can understand better what

you are saying

The right ear is patients good ear.

Give information here for betteracuity

Patient has a low educationalattainment so its essential to useterms or statement within his level ofcomprehension.

To evaluate whether the patient

understood what was asked

For the patient to understand the

importance of medications,treatments and health teachings inrelation to the disease

For patient to understand better the

information.

It is easier to understand what is

abnormal if the normal anatomy andphysiology of the lungs is discussed

first; to provide information andawareness to the patient

To let them know what to expectduring the disease period, thenecessary interventions and to avoid

the spread of the disease.

During the initial 6-8 weeks after

discharge, patient is at great risk for

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coughing exercises.

4. Outline steps to enhancegeneral health and well-being

such as balanced rest andactivity, well-balanced diet,

avoidance of crowds duringcold/flu season and persons

with respiratory infections.

6. Encourage patient and familymembers to ask questions.

7. Encourage patient and

significant others to askquestions about Pneumonia.

7. Instruct patient to weareyeglasses during interactionor when reading materials are

provided.

COLLABORATIVE:

Health Teachings:

1. Identify available resourcessuch as health clinics and

health centers or supportgroups especially in their

community to validateinformation post discharge.

2. Stress importance of

continuing medical follow-upcheck up and obtainingvaccinations andimmunizations.

3. Encourage the patient to seek

dietary consultation regardingthe appropriate foods for his

condition.

4. Inform the physician of lack ofknowledge on the patients

condition, needs, andtreatment given.

5. Emphasize the need of

continuing antibiotic therapy

for prescribed period.

6. Instruct patient to keep a list

of medications he is taking andto keep in a place where an

assigned significant other or

recurrence of pneumonia.

To increase naturaldefenses/immunity, limit exposure to

pathogens

For clarification of information

For clarification of information

To aid the patient because he hasvision problems

Patient needs accessible knowledgeespecially from the rural health

center because it is where he initiallyseeks assistance when he gets sick.

May prevent recurrence of

pneumonia and or relatedcomplications

For the patient and significant others

to have thorough knowledge for whatis good and what is contraindicated

for the disease.

For appropriate physicianinterventions to the disease process

Early discontinuation of antibiotics

may result in failure to completely

resolve the infection and may lead toan increase in resistance ofmicroorganisms to the drug.

So that in case of questions or

emergency significant others andfamily would readily have a guide as

to what his medications are all about.

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family members have access incase of questions andemergencies.

7. Advise patient and significantothers to have a hearing

consultation with a doctor, ifneeded.

8. Teach patient and significantothers on how and when totake the different medications

and treatment, what kind ofactivities or exercises to be

done, how to maximize theavailable community

resources, when to visit the

clinic for check-up, the properdiet to be followed, and upliftspirituality and awareness of

culture upon discharge.

To provide immediate interventionson the patients hearing loss

Provide knowledge to patient inrelation to his further recovery.

Evaluation:

After 2 hours of nursing and medical interventions, patient was able todifferentiate Tuberculosis from Pneumonia. Furthermore, he also learned that he

was admitted due to Pneumonia and verbalized understanding and compliance with

the medications, treatments, and healthy teachings, such as performance ofbreathing and coughing exercises, use of available community resources, and followup medical consultations and care.

Patient hears and understands questions and instructions clearly with his

right ear. He uses eyeglasses when reading printed materials provided.

Discharged plans, reviewed, clarified and understood by patient.

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NURSING DIAGNOSIS

Activity Intolerance may be related to exhaustion associated with interruptionin usual sleep pattern due to discomfort, persistent coughing, and dyspnea asmanifested by:

a. Subjective: Kulang gid akon tulog kay sige-sige akon ubo kunggab-i siguro mga tatlo lang asta lima ka oras akon tulog, kis-a gain gasakitna akon dughan ka-ubo.b. Subjective: Galingin ulo ko kung mag bangon kag magkadto sa

banyo.c. Subjective: Gapalanakit man lang tiil ko kag tuhod kung malamig ang

klima.

d. Minimal aching pain felt on both ankles and knees rated as 3 in a scaleof 0-10

e. Requires one-person assistance with ambulation

f. Can only perform limited range of motion on both lower extremities

Definition:

Insufficient physiological energy to endure or complete requir\d or desired

daily activities

Goals of Care:

a. Within 8 hours of nursing and medical interventions, patient will be ableto have stable blood pressure ranging from 110/70 to 120/80 mmHg and

respiratory rate of 18-22 breaths per minute.

b. Within 4 to 5 hours of nursing and medical interventions, patient will be

able to perform and demonstrate a measurable increase in tolerance toactivity such as getting out of bed and ambulating in the room andhallway with supervision.

c. Within 4 hours of nursing and medical interventions, patient will beassisted with bathing, grooming and dressing.



1. Continuously monitor vital

signs every 4 hours.

2. Monitor for orthostatic bloodpressure in lying, sitting, or

standing position.

3. Assess patients balance inself-care activity performance.

4. Observe and evaluate responseto activity such as performance

of passive and active range ofmotion exercises; bed mobility,transfer, ambulation, hygiene,grooming, dressing, eating,

toileting, bathing.

To obtain baseline data; An alteration

in any of the result may indicatephysiologic signs of intolerance.

To prevent patient accidents such as

falling caused by dizziness or loss ofbalance

Determines extent of tolerance andto facilitate the choice ofinterventions and assistance or set upneeded in activities

Lack of sleep may lead to fatigue.

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5. Assess patients sleep pattern.

6. Identify factors contributing toactivity intolerance such as:

a. lack of sleepb. lack of appropriate foodc. weight loss

d. severity of diseasecondition


1. Provide a quiet and peacefulenvironment conducive forsleep. Limit visitors during

patients rest periods.

2. Assist the patient to sit or backto bed if patient complains of

dizziness with activity andslowly assume a comfortableposition for rest and sleep.

3. Provide set-up or 1 personassistance with transfers,ambulation, toileting, bathing,

grooming and dressing asneed.

4. Provide comfort measures like

backrubs, slow change inpositioning, relaxation, and

breathing exercises.

5. Provide rest periods during andafter activities and routinenursing care.

6. Keep personal items withinreach (glass, water, pitcher,eyeglasses, personal hygiene,

and grooming materials) atbedside.

7. Gives praise and recognition

for attempted or accomplishedtask.

Health Teachings:

1. Evaluate patients response toactivity.

2. Explain importance of rest in

treatment plan and necessityfor balancing activities with

Reduce stress and excessstimulation; To promote rest.

To promote rest and relaxation andlimit the effects of orthostatic

hypotension

Reduce stress and excess stimulationand to promote rest.

To give time for rest and so that

activities will not disturb when patientis resting; Reduce fatigue and

facilitates ventilation; Suddenpositional changes can lead to

orthostatic hypotension

To avoid fatigue and as energy saving

measures

Lessens discomfort and decrease the

risk for orthostatic hypotension

To give time for rest and reducefatigue

To prevent orthostatic hypotension;for convenience and easy access

especially when patient is at bed

To motivate patient to continue doingactivities and promote independence

Establishes patients capabilities orneeds and facilitates choice of

intervention

Rest is maintained during acutephase to decrease metabolic

demands thus conserving energy for

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rest.

3. Instruct patient to avoidsudden position changes such

as:a. transferring from bed to

chairb. transferring from bed to

ambulation

4. Instruct patient to stop activitywhen dizzy or in pain.

5. Teach and demonstrate how to

perform deep breathingexercises by inhaling through

the nose while keeping the

mouth close and exhalingslowly through the mouth.

6. Instruct patient and significantothers to monitor response to

activity and to recognize signsand symptoms that indicates

alterations in activity levelsuch as:

a. tachycardiab. tachypnea

c. dyspnead. dizziness after activity

e. poor balance

7. Give information to patientthat provides evidence of daily

progress.

8. Instruct patient to ambulateand to avoid prolonged

standing and weight bearing toknees and ankles.

COLLABORATIVE:Treatments/Therapeutic:

1. Administer oxygen whenneeded as ordered.

healing.

To prevent orthostatic hypotension

To avoid accidents such as falling

To ensure effectiveness of the

exercises and so that patient will beable to deal with his discomforts

independently

Determine benefits of activities andto watch activity intolerance

Gives awareness to patients currenthealth status and to sustain

motivation

Avoid pooling of secretions andpromote lung ventilation

To provide oxygenation, relievedyspnea, and decrease work of

breathing during activities

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Evaluation:

After 8 hours of nursing and medical interventions, patient was able tomaintain stable blood pressure ranging from 110/70 120/70 mmHg andrespiratory rate between 18 22 breaths per minute.

After 5 hours of nursing and medical interventions, patients activities werespaced and scheduled with rest periods.

Patient demonstrated good balance in ambulation.Patient required one-person assistance in bathing, grooming and dressing.

Patient can demonstrate good deep breathing techniques.He was gradually performing activities like getting out of bed, without feeling

of dizziness and able to go to the bathroom with one-person assistance.He had 2-3 hours of uninterrupted sleep in the afternoon and expresses relief

and feeling rested when he woke up.

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NURSING DIAGNOSIS

Potential for spread of infection may be related to inadequate primaryrespiratory defense secondary to decreased ciliary action, stasis of respiratorysecretions.

Definition:

At risk for development of further infection other than present disease.

Goals of Care:

Within 1-2 hours of medical and nursing interventions, patient will be able to

identify interventions to prevent/reduce the risk of infection such as hand washing,proper disposal of sputum and compliance to medications.

Within 1 week of medical and nursing interventions, patient achieves timely

resolution of pneumonia.



1. Continuously monitor vitalsigns especially temperature

every 4 hours.

2. Assess for sudden changes or

deterioration in condition suchas recurrence of cough,increasing chest pain, return offever and changes in sputum

characteristics.


1. Change position frequently andprovide good pulmonary toilet.

2. Perform hand washing beforeand after patient care.

3. Screen visitors of patient.

4. Provide or maintain a clean

environment by disposing of

sputum receptacle, providingtissue for phlegm or sputum,disinfecting surrounding area,bedpans, urinals, changingwater pitcher and glasses.

Any alterations may indicateinfection.

Parameters that may indicate

infection

To mobilize secretions for easyexpectoration and prevents spread of

infection.

Hand washing may be the simplestbut it is the most important key to

prevention of hospital-acquiredinfection.

Individual is at increased risk for

development of infection and spreadof infection.

To minimize presence of pathogensthus decreasing risk for infection.

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Health Teachings

1. Demonstrate and encouragegood hand washing techniqueto patient and family members

and visitors.

2. Encourage adequate rest withmoderate exercise totolerance.

3. Instruct patient to providedisposable tissue for

expectoration.

4. Instruct patient concerning the

disposition of secretions suchas expectoration rather than

swallowing.

5. Instruct patient to providewaste receptacles for phlegmand sputum.

6. Encourage patient to perform

deep breathing and coughingexercises.

7. Increase oral fluid intake to

1.5-2 liters per day.

8. Instruct patient not to put

hands/fingers to face, mouthor nose.

Collaborative:

Assessment/Diagnostic

1. Monitor effectiveness of MyrinForte.

2. Monitor for side effects ofMyrin Forte such as blurred

vision, fever, malaise, drynessof mouth, and flu-like

syndrome.

3. Monitor follow-up chest x-ray.


1. Obtain sputum

culture as indicated.

Hand washing technique preventscross infection

To stimulate immune system

recovery

Proper disposal of infectious materialsinhibits spread of infection.

Proper disposal of infectious materials

inhibits spread of infection.

Proper disposal of infectious materials

inhibits spread of infection.

Maximizes lung expansion andmobilization of secretions toprevent/reduce atelectasis and

accumulation of sticky, thicksecretions

To liquefy secretions and counteract

effect of Myrin Forte which is drynessof mouth.


Drugs that protects patient fromacquiring Tuberculosis

To plan for appropriate interventions

and to limit the side effects ofmedications

To determine if patient responded totreatment and medications.

May be needed to identify pathogensand appropriate antimicrobials.

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2. AdministerMyrin Forte as ordered.

Health Teachings

1. Instruct patient to comply withmedications such as Myrin

Forte and Ceftazidime(Fortum).

The maintenance for tuberculosis.

Compliance to medications decreaserisk for spread of infection and

resolution of the disease condition(pneumonia and TB maintenance).

Evaluation:At the end of 1 hour of nursing and medical interventions, patient was able to

identify and perform ways to prevent infection such as hand washing, properdisposal of sputum and compliance to medications; patients significant others,

family members, visitors demonstrate good hand washing technique.

At the end of 1 week of medical and nursing interventions, patient achievedtimely resolution of pneumonia.

nursing diagnosis[1][1].finalgid niya

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