ASSESSMENT Subjective: pag ubo ko ng ubo nawawalan n ko ng ganang kumain Objective: - weakness - Pale conjunctiva - Pale mucous membrane

- Poor muscle tone - Decreased capillary - Loss of appetite - Sore tonsils

NURSING DIAGNOSIS Risk for Imbalanced nutrition: less than body requirements related to persistent cough and mucus production

OBJECTIVES Short-term: After 30 minutes of nursing interventions the client will be able to: a.Verbalize understanding on the importance of proper diet. b.Enumerate foods to be included in his diet.

NURSING INTERVENTION - Plan with the client his desired meals and discuss eating habits, including food preferences, intolerances/ aversions

RATIONALE - For the client to be aware of the needed nutrients by his body to nourish himself. Also, giving sources of these nutrients helps the client to easier familiarize himself as to what foods he may include in his diet. - may have anegative effect on appetite or eating - Education provides ample information that the client may not be aware of, hence leading to the kind of eating habits and diet he

EVALUATION Short-term: Goal met. At the end of the nursing interventions, the client is able to understand the importance of proper diet. He is also able to select the meals he wants to eat, which are good sources of the nutrients needed by him.

- prevent or minimize unpleasant odor or sights - Educate the client regarding the importance of eating healthy foods and its benefits to his body.

is following. Long-term: After 1 day of nursing interventions, the client will be able to: a.demonstrate changes in his diet as manifested by proper food selection - Suggest ways that may assist the client in eating a. Ensure pleasant environment. b. Facilitate proper positioning - A pleasant environment gives the client a relaxed feeling and will not spoil his appetite. And proper positioning reduces the risk of aspiration and heartburn. - Caffeinated beverages may decrease the appetite and will make the client feel full easily. - Junk foods have empty calories that provide no nutritional help to the client. Long-term: Goal met. After 1 day of nursing interventions, the client was able to: a.demonstrate changes in his diet as manifested by proper food selection

After 1 week of nursing interventions, the client will be able to: a.demonstrate adequate weight gain

- Instruct the client to avoid caffeinated beverages.

Goal not met because of lack of time

- Instruct the client to avoid junk foods.

- Instruct the client to follow the prescribed number of servings of the meals included in his meal plan.

- Too much food intake is not good for the body. Too much weight gain, which is out of the expected, may bring about complications, such as diabetes mellitus. - To provide nourishment to the client that keeps both of them healthy.

- Encourage the client to maintain the intake of the healthy foods needed by his body to achieve ideal body weight.

ASSESSMENT

NURSING DIAGNOSIS

OBJECTIVES Coping as evidenced by often demonstrating ability to -Identify effective and ineffective coping patterns -Verbalize sense of control -Report decrease in negative feelings -Modify lifestyle as needed

NURSING INTERVENTION - Provide an atmosphere of acceptance.

RATIONALE - Establishing rapport is essential to a therapeutic relationship and supports the client in selfreflection. Recognizing problems and sharing feelings is best brought about in an atmosphere of warmth and trust. - Factual information serves as a foundation for Patient to explore feelings and alternative coping strategies. Stressed clients often misunderstand facts and require frequent clarification so that appropriate

EVALUATION Goal not met because of lack of time

Subjective: Risk for nahihiya akong ineffective lumapit sa ibang Coping tao dahil dito sa ubo ko Objective: -depression -self-destructive feelings -paranoia and loss of contact with real world -hopelessness -impulsiveness

- Provide factual information Social Support as concerning the evidenced diagnosis, by substantial treatment, reports of and prognosis. -Willingness to call on others for help -Emotional assistance provided by others

conclusions can be drawn. Having valid information helps relieve stress. - Arrange situations that encourage him autonomy. Give him as many opportunities as possible to make decisions/choices for himself. - Explore with his previous methods of dealing with life problems. - Enhances a sense of control, personal achievement, and self-esteem.

- Present and past coping status assists both Patient and him wife in capitalizing on successful methods, identifying ineffective strategies, and developing new skills more appropriate to the present situation. Also determines risk for

inflicting selfharm. - Encourage verbalization of feelings, perceptions, and fears. - Open, nonthreatening discussions facilitate the identification of causative and contributing factors. - Assists to develop appropriate strategies for coping based on personal strengths and previous experiences. Improves selfconcept and sense of ability to manage stress. - Assessing family interaction serves as a basis for identifying Patients support systems or lack thereof.

- Encourage to identify his own strengths and abilities.

- Observe the degree of family support.

- Determine barriers to using support systems.

- Although adequate support systems may be available, Patient may not be using them or may be using them ineffectively. - Supporting patient in acknowledging changes in him appearance conveys acceptance and provides a foundation for him to begin to adjust - Family and friends are often willing but unsure how to help. Identifying specific strategies such as praise and encouragement during rehabilitation and healing will promote acceptance of change.

- Involve wife, family, and friends in the care and planning.

- Discuss with concerned others how they can help.

ASSESSMENT Subjective: paminsan minsan pakiramdam ko nang hihina ako Objective: -weakness -restless -RR of 27 cpm -breathes with much exertion and with the use of accessory muscles. - on oxygen therapy at 2 L/min

NURSING DIAGNOSIS Risk for activity intolerance related to Imbalance between oxygen supply and demand

OBJECTIVES That after six hours of nursing care management my patient will be able to: - decreased RR from 27 cpm to 16-20 cpm - participate willingly in necessary or desired activities - report measurable increase in activity tolerance - be free of any aggrevation of illness.

NURSING INTERVENTION -adjusted activities - Teach methods to increase activity levels gradually and plan care to carefully balance rest periods with activities - provide positive atmosphere while acknowledging difficulty of the situation for the client - assist with activities and monitored clients use of assistive device - assist client in learning and demonstrating appropriate safety measures

RATIONALE - to prevent Overexertion - to conserve energy and reduce fatigue or weakness

EVALUATION Goal met after 6 hours of nursing care management patient was able to: - have an RR of 22 cpm from 27 cpm - participate willingly in necessary or desired activities - report measurable increase in activity tolerance - felt a little relief when provided with nebulization

- helps to minimize frustration and rechannel energy

- to protect client from injury

- to prevent injuries

- give client information that provides evidence of daily/weekly progress. - Teach and supervise effective coughing techniques.

- to sustain motivation

- Proper coughing techniques conserve energy, reduce airway collapse and lessen clients frustration. - Hydration helps to reduce secretions therefor improving the supply and demand of oxygen.

- Teach the client to maintain adequate hydration by drinking 8 to 10 glasses of fluids each day (if not contraindicated) and increasing the humidity of the ambient air

ASSESSMENT Subjective: Hirap akong huminga Objective: - Increased RR 27 - Cardiac Rate 108 - Abdominal breather With crackles - With wheezes - With circum oral cyanosis - With nasal flaring, crackles, wheezing, and cyanosis

NURSING DIAGNOSIS Impaired gas exchanged related to retained secretions as evidenced by tachycardia, tachypnea, crackles, wheezing, and cyanosis

OBJECTIVES

NURSING INTERVENTION

RATIONALE - Serves as baseline data for any further complication - to know what possible condition the patient is experiencing - It maximize lung expansion thus sustain open airway - It promotes optimal chest expansion - to prevent aggravation of the disease

EVALUATION Short Term Goal partially met. Long Term Pt. was able to verbalize in understanding of the disease and its course of treatment.

Short Term - Assessed Within 15 mins respiratory status of duty, difficulty of breathing will be lessened. - Auscultated lung fields Long Term After 1 day Pt will demonstrate improvement in - Elevate the head ventilation and of the bed 45 adequate (semi-fowlers) oxygenation position. within normal limits and having - Encouraged deep absence symptoms controlled of respiratory breathing distress exercise. After 3 days Pt will be able to verbalize understanding regarding factors that would contribute to exacerbation of disease - Advised the pt to keep calm during episodes of breathing difficulty - Regularly monitor the clients respiratory rate and pulse

- Prompt recognition of deteriorating respiratory function can

oximetry, ABG results, and manifestations of hypoxia or hypercapnia. Report significant changes or lack of response promptly. - Administer low flow oxygen therapy (1 to 3 L/min or 24 % to 31% Flo2) as needed via nasal prongs or a highflow venture mask.

reduced potentially lethal outcomes.

- Oxygen corrects existing hypoxemia. Excessive increases in o2 (55% to 70% Flow) may diminish respiratory drive and increases carbon dioxide retention further. - Environmental changes may lessen the clients perception of suffocation.

- During episodes, open doors and curtains and limit the number of people and unnecessary equipment in the room. Provide a fan if the client perceives a benefit from the moving air.

- Encourage the use of breathing retraining and relaxation technique.

- A feeling of self control and success in facilitating breathing helps reduced anxiety.

ASSESSMENT Subjective Nahihirapan ako huminga Objective - Use of accessory muscles noted - Dyspnea - Productive Cough - Increased RR 27 - Cardiac Rate 108 - Abdominal breather With crackles - With wheezes

NURSING DIAGNOSIS Ineffective airway clearance related to increased production of secretions

OBJECTIVES After 2 hours of nursing interventions, the client will demonstrate behaviors to improve airway clearance like cough effectively and expectorate secretions.

NURSING INTERVENTION - Assessed respiratory status

RATIONALE - Serves as baseline data for any further complication - to know what possible condition the patient is experiencing - Facilitates respiratory function by gravity - Precipitators of allergic type or respiratory reactions that can trigger or exacerbate onset of acute episode - Rhonchi present in the large airways may impair patency.

EVALUATION After 2 hours of nursing interventions, the patient was able to demonstrate behaviors to improve airway clearance. e.g. cough effectively and expectorate secretions.

- Auscultated lung fields

- Assist patient to assume position of comfort, elevate head of the bed - Keep environmental pollution to a minimum

- Monitor lung sounds every 4-8 hours and before and after coughing episodes.

- Teach the client to maintain adequate hydration by drinking 8 to 10 glasses of fluids each day (if not contraindicated) and increasing the humidity of the ambient air. - Teach and supervise effective coughing techniques.

- Hydration helps to reduce secretions.

- Proper coughing techniques conserve energy, reduce airway collapse and lessen clients frustration. - Chest physical therapy techniques use forces of gravity and motion to facilitate secretion removal.

- Perform chest physical therapy, if needed, and instruct the client and significant others in these techniques.

- Reassess the condition of the oral mucous membranes and perform or offer oral care every 2 hours.

- Thick secretions line the mouth when the client coughs; oral care removes them.