PRIORITY PROBLEM #2: Nursing Diagnosis: Impaired Breathing Pattern related to decreased lung expansion secondary to accumulation of fluid

in the pleural cavity Date of Assessment: August 20, 2013 Assessment Subjective Cues: Objective Cues: RR 61cpm Crackles noted Nasal Flaring Use of accessory muscles Restlessness Goals and Objectives Short term: After 30 minutes of nursing interventions, the patient will demonstrate appropriate coping behaviors and methods to improve breathing pattern. Long term: After 2 weeks of nursing interventions, the patient would be able to apply techniques that would improve breathing pattern and be free from signs and symptoms of respiratory distress. Nursing Interventions and Rationale Independent: 1. 1. Elevated head of the patients bed R - to promote lung expansion. 2. Provided relaxing environment R - to promote adequate rest periods and limit fatigue. 3. Helped and teached the patient to cough and breathe in effective. R - That supresses the painful area when coughing and breathing deeply. 4. Maximized respiratory effort with good posture and effective use of accessory muscles. R - to promote wellness. Galisod ko ug ginhawa, as verbalized.

Collaborative/Dependent: 1. Administered prescribed medications as ordered. (medication?)

2. Administered supplemental oxygen as ordered to maximize oxygen available for cellular uptake. Evaluation Short term: After 3 hours of nursing interventions, goals met. Patient demonstrated appropriated coping behaviors and methods to improving breathing pattern. Long term: Goals not met. After 2 weeks of rendering nursing interventions, patient was still in respiratory distress.

PRIORITY PROBLEM #3: Nursing Diagnosis:

Impaired effusion

Gas

Exchange

related

to

alveolar-capillary

membrane changes and respiratory fatigue secondary to pleural

Date of Assessment: August 23, 2013 Assessment Subjective Cues: Patient verbalized that she experienced shortness of breath or difficulty of breathing. Objective Cues: Use of accessory muscles Crackles noted Nasal Flaring Restlessness RR- 27cpm With productive cough noted O2sat 85% Goals and Objectives Short term: After 8 hours of nursing interventions the patient will participate in treatment regimen within level of ability and situation Long term: After 2-3 days of nursing interventions the patient will demonstrate improved ventilation and adequate oxygenation of tissues by ABG's within normal limits and absence of respiratory distress. Nursing Interventions and Rationale Independent: 1. Monitored respiratory rate, depth and rhythm. R-To obtain baseline data 2. Elevated head of the bed and position client appropriately. R-To enhance lung expansion 3. Instructed frequent position changes and deep-breathing exercises R-To promote optimum chest expansion 4. Provided adequate rest periods and limit activities to within client tolerance R- Helps limit oxygen needs and consumption Collaborative/independent: 1. Provided supplemental oxygen via nasal cannula 6L/min.

R-To correct/ improve existing deficiencies 2. Administered prescribed medications such as bronchodilators combivent 1neb q6h R-To treat underlying condition. Evaluation Short term: After 8 hours of nursing interventions, the patient was able to cooperatively participate in treatment regimen. Goals met. Long term: Goals not met. After 2 weeks of rendering nursing interventions, patient was still in respiratory distress.

PRIORITY PROBLEM #4: Nursing Diagnosis:

Fatigue related to decreased in oxygen supply Date of Assessment: August 20, 2013 Assessment Subjective Cues: Dali rako gakapuyon, mghangos ko, as verbalized. Objective cues: RR 26cpm 02 Sat 85% (+) Restlessness Muscle strength upper extremities ?/5; lower extremities ?/5 Weak in appearance Easy fatigability noted Goals and Objectives Short term: After 4 hours of nursing interventions, the patient will be able to identify basis of fatigue and individual areas of control.

Long term: After 2 days of nursing interventions, the patient will be able to perform ADLs at level of ability. Nursing Interventions and Rationale Independent: 1. Scheduled activities for periods when patient has the most energy R - to maximize participation 2. Provided calm environment R - to minimize fatigue 3. Assisted with self-care needs and ambulation as indicated R - to help patient cope with fatigue 4. Instructed in stress management techniques, e.g., breathing exercises 5. Plan and provided rest periods between activities R - to provide adequate rest and reduce unnecessary energy expenditure. Collaborative/dependent: 1. Provide supplemental oxygen, in 6LPM, as indicated.

Evaluation Short term: After 4 hours of nursing interventions, goals were met. Patient was able to identify basis of fatigue and her areas of control. Long term: After 2 days of nursing interventions, goals were partially met. Patient was able to perform ADLs but there is presence of respiratory distress.

PRIORITY PROBLEM #5: Nursing Diagnosis: Anxiety related to present illness as evidenced by poor eye contact, anxious and low tone of voice

Date of Assessment: August 20, 2013 Assessment Subjective Cues: Sige kog huna-huna sa akong kahimtang as verbalized by the patient. Objective cues: the patient appears tensed and anxious. poor eye contact low tone of voice Goals and Objectives Short term: After 8 hours of giving nursing interventions, the patient will be able to lessen or decrease anxiety as evidenced by expressing feelings regarding the situation. Long term: After 2 days of giving nursing interventions, the patient will be able to verbalized awareness of feeling and healthy ways to deal with them and demonstrate decreasing level of anxiety. Nursing Interventions and Rationale Independent: 1. Assured patient of confidentiality within limits of situation. R: provides reassurance and opportunity for patient to problem solve solutions to anticipated situations. 2. Maintained frequent contact with patient, talk with patient. R: Provides assurance that patient is not alone or rejected: conveys respect for and acceptance of the person, fostering trust. 3. Provide reliable and consistent information and support from S.O. R: Allow for better interpersonal interaction and reduction of anxiety and fear. Collaborative/dependent: 1. Administer antianxiety medication as needed. (medication?) R: May be useful for brief periods of time to help patient handle feelings of anxiety related to diagnoses and personal situation. 2. Instructed the SO not to leave the client unattended be with clients sie. R: to help minimize frustration. Evaluation Short term: Goals met. After 8 hours of giving nursing interventions the patient was able to lessen or decrease anxiety as evidenced by expressing feelings regarding the situation.

Long term: Goals met. After 2 days of giving nursing intervention the patient was able to verbalized awareness of feeling and healthy ways to deal with and demonstrate decreasing level of anxiety.

PRIORITY PROBLEM #6: Nursing Diagnosis: Activity intolerance related to insufficient oxygen for activities of daily living

Date of Assessment: August 20, 2013 Assessment Subjective Cues: Dili ko makabuhat sako gusto buhaton as verbalized by the patient. Objective cues: generalized weakness limited range of motion as observed use of accessory muscles during breathing (+) DOB Goals and Objectives Short term: After 3-4 hours of nursing interventions, the patient will use identified techniques to improve activity intolerance. Long term: After 2 days of nursing interventions, the patient will report measurable increase in activity intolerance. Nursing Interventions and Rationale Independent: 1. Established rapport. R: To gain clients participation and cooperation in the nurse patient interaction. 2. Monitored and record vital signs. R: To obtain baseline data. 3. Assessed patients general condition. R: To note for any abnormalities and deformities present within the body. 4. Adjusted clients daily activities and reduce intensity of level. R: To prevent strain and overexertion. 5. Encouraged patient to have adequate bed rest and sleep. R: To conserve energy and promote safety. 6. Assisted the client in ambulation. R: fatigue affects both the clients actual and perceived ability to participate in activities. 7. Assisted the client in a semi-fowlers position. R: to maintain an open airway. Collaborative/dependent: 1. Instructed the SO not to leave the client unattended. R: to help minimize frustration and rechannel energy.

Evaluation Short term: Goals not met. After 4 hours of giving nursing interventions, the patient still in activity intolerance. Long term: Goals met. After 2days of giving nursing interventions, the patient was able to report measurable increase in activity intolerance like tooth brushing, taking a bath.

PRIORITY PROBLEM #7: Nursing Diagnosis: Self- care deficit related to easy fatigability secondary to difficulty in breathing

Date of Assessment: August 20, 2013 Assessment Objective cues: Restlessness observed Poor hygiene observed Weakness observed Decreased energy level observed. Goals and Objectives Short term: After 8 hours of giving nursing interventions, the patient would be able to perform self-care activities within level of own activity.

Long term: After 2 days of giving nursing interventions, the patient will be able to demonstrate lifestyle compensatory techniques to meet self-care needs. Nursing Interventions and Rationale Independent: 1. Avoided doing things for the patient that the patient can do for self but provide assistance as necessary. 2. Provided positive feedbacks for efforts. 3. Encouraged family to assist with care whenever possible. 4. Maintained a supportive firm attitude. Allow patient sufficient time to accomplish any tasks. 5. Provided self- help devices. Collaborative/dependent: 1. Followed doctors order Evaluation Short term: Goals partially met. Patient was able to performed self-care activities. Long term: ----------------------------