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S: “hindi siya Patient was STO: after 8 hours of Dx: Monitor Indicative of Goal will be met if:
makahinga ng diagnosed to have nursing intervention, respirations and respiratory distress
maayos” as colon cancer. Cancer patient will be able breath sounds, noting Patient’s breathing
verbalized by SO cells may reached the to: rate and sounds pattern is maintained
lungs through the as evidenced by
blood stream. Cancer a. Maintain patent eupnea, normal skin
cells then irritates the airway with To rate dyspnea with color, and regular
O: Dyspnea breath sound Note the respiratory
pleura.Irritated tissue presence/degree of aid in quantifying and
Tachypnea (RR:26 makes extra fluid clear tracking changes in rate/pattern.
b. Verbalize dyspnea
) which eventually respiratory distress Goal will be
causes fluid build up understanding partially met if:
decreased tactile preventing lungs from of the health
Fremitus inflating during teaching given Patient’s refrain from
to improve To increase amount using accessory
breathing this causes
pale in airway such as: of thick secretions muscle but still
dyspnea.
appearance -DBE and suggest development experiencing
Decrease amount and of secondary problem
pursed-lip tachypnea.
non productive characteristic of eg. DHN, infection,
breathing
Cough sputum/secretions peripheral edema,
-proper body
Nasal flaring positioning local hemorrhage
Goal will be unmet
if:
Respiratory depth
changes Patient’s breathing
LTO: after 24 hours
of nursing pattern is not
Altered chest Expectoration maybe
intervention, the maintained as
excursion difficult when
patient will be able to evidenced by
Use of accessory secretion is thick Dyspnea, Tachypnea,
demonstrate behavior
muscles to improve airway Nasal flaring
Note the ability to
such as: expectorate
oxygen inhalation -performing DBE and mucus/cough To determine ability And Use of accessory
via canula @ 3 lpm pursed lip breathing effectively to protect own airway muscles
Assist patient
frequent DBE Accumulation of
secretion can impair
circulation/oxygenatio
n of vital organs and
tissues
Note cyanosis/change
in skin color including
mucus membrane
and nail beds Creates resistance
against out flowing
air to prevent
collapse
To facilitate breathing
and lung expansion
Provide psychological
support
Dyspnea is caused by
excessive
accumulation of fluid
Maintain chest in lungs, mainataing
drainage chest drainage helps
in alleviating dyspnea
Edx: Demonstrate
DBE and purse lip Reduce anxiety that
breathing may increase oxygen
demand
Instruct SO to reduce
clothing and change For effective bed rest
into loosely clothes
Instruct SO to provide
/maintain
quiet/relaxing
environment
PROBLEM: Colon Cancer Metastasis
ASSESSMENT EXPLANATION GOAL INTERVENTION RATIONALE EVALUATION
- Inability to accept or
Each person receive needed help
Assess role may see the
expectations of situation on - Inappropriate or
family own individual poorly communicated
members and manner, and family rules
encourage clear
discussion identification
about them and sharing of Modification:
these
expectations Identify community
promote resources that may
understanding be helpful in dealing
with particular
situations (e.g.,
telephone hotlines,
Provide clues
self-help groups,
about
interventions educational
that maybe opportunities, social
Assess energy appropriate to service agencies, and
direction eg. assist patient counseling centers).
Are efforts at and family in Groups that come
resolution or directing together for mutual
problem energies in a support or
solving more effective information exchange
scattered manner. can be beneficial in
helping family reach
goals.
Affects
patient or SO
reaction to
diagnoses,
treatment and
Note cultural or outcomes of
religious belief cancer
Helpless
feeling may
contribute to
difficulty
adjusting to
TX: diagnoses of
cancer and
listen to
cooperating
expression of
with treatment
helplessness
regimen
provides
felling of
sympathy and
promotes
individuals
sense of worth
and
Deal with competence in
family ability to
members in a handle current
warm, caring, situation
respectful way.
Provide
information
and reinforce Communicat
as necessary. es acceptance
of the reality
the patient and
the family are
Acknowledge facing
the difficulty of
the situation
Feelings of
anger are to be
expected when
individuals are
EDX:
dealing with
Encourage the difficult or
appropriate potentially fatal
expressions of illness of
anger without cancer.
reaching Appropriate
negatively on expression
them enables
progress
towards
resolution of
the stages of
the grieving
process.
Most people
have
developed
effective
coping skills
that can be
Encourage useful with the
use of previous current
successful situation
coping
behaviors