Ineffective Breathing Pattern related to fatigue as manifested by Tachypnea: ASSESSMENT DIAGNOS RATIONAL PLANNING INTERVENTION IS E SUBJECTIVE: Medyo nahihirapan

nga akong huminga, as verbalized by the client. Medyo nanlalambot nga ako, as verbalized by the patient. OBJECTIVES: Tachypnea *RR- At A1; 4:00pm A2; 6:00pm PR at 4:00pm; 40cpm PR at 6:oopm; 26cpm Ineffective Breathing Pattern related to respirator y muscle fatigue as manifeste d by tachypnea Inspiration and/or expiration that does not provide adequate ventilation. GOAL: After the shift, the client will establish a normal/effective respiratory pattern. OBJECTIVES: After nursing interventions, the patient will be able to: Verbalize awareness of causative factors. The nurse will: INDEPENDENT: Established therapeutic nurse-client relationship conveying of caring. Assessed the patient including reviewing patients chart. Monitored v/s. especially the respiratory rate. Elevated the head of bed or have the client sit up in a chair. Encouraged position of comfort. Maintained

RATIONALE To develop a sense of trust To identify the causative or contributing factors. To watch for any deviation in his vital signs. To provide relief of causative factors. To provide relief of causative factors. To limit level of anxiety.

EVALUATI ON Goal Met. After the shift the client was able to establish an effective respiratory pattern as evidenced by respiratory rate of 26 cpm and verbalizatio n that difficulty of breathing was relieved.

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calm attitude while dealing with the client. Imbalanced nutrition less than body requirements related to Stomatitis secondary to radiation therapy: ASSESSMENT DIAGNOS RATIONAL PLANNING INTERVENTION RATIONALE EVALUATI IS E ON SUBJECTIVE: Hindi ako makakain pakiramdam ko 23 sakol lng ng pagkain busog na agad ako, as verbalized by Mr.L.M.M. OBJECTIVES: Upon Inspection: Stomatitis Sore buccal cavity Pale mucous membranes Upon palpation, tenderness in the right upper epigastic area was noted. Laboratory Imbalance d nutrition less than body requireme nts related to stomatitis secondary to radiation therapy Intake of nutrients insufficient to meet metabolic needs. SHORT-TERM GOAL: After the shift, the client will verbalize understanding of causative factors when known and necessary interventions. OBJECTIVES: After nursing interventions, the patient will be able to: Show willingnes s to eat more frequent than his usual food preference s. LONG-TERM GOAL: The nurse will: INDEPENDENT: Established therapeutic nurse-client relationship conveying of caring. To develop a sense of trust. To identify the causative or contributing factors. To watch for any deviation in his vital signs. To promote normal body temperature. All factors that can be affect ingestion and digestion of nutrients. To establish nutritional plan that meets the clients needs. Goal Unmet. After the shift the client was able to eat frequent and small meals.

Assessed the
patient including reviewing patients chart. Monitored v/s.

TSB
rendered.

Determined
clients ability to chew,

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results: Sodium: Result:124.2 mEq/L Normal values: 135-145mEq/L Interpretation: Below Normal value Potassium: Result: 3.41 mEq/L Normal Values: 3.5-5 mEq/L Interpretation: Below normal value

The client will display normalization of laboratory values and be free of signs of malnutrition.

swallows, and taste food. Evaluated teeth and gums for poor oral health.

To reduce possibility of early satiety.

Provided diet
modification s: Soft Diet including small frequent meals.

Instructed to
promote adequate fluid intake and to limit fluids 1 hour prior to meal.

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Disturbed body image related changes in physical appearance secondary to Chemotherapy: ASSESSMENT DIAGNOSIS RATIONAL PLANNING INTERVENTION RATIONAL E E SUBJECTIVE: Panlalagas ng buhok nga daw ang isang sintomas ng aking sakit na wala naman akong magagawa, as verbalize by the patient. OBJECTIVES: Acknowledge ment of ones body Unintentional hiding Disturbed body image related changes in physical appearance secondary to Chemotherap y Confusion or dissatisfacti on in mental pictures of ones physical self. GOAL: After the shift, the client will recognize body image change to self-concept in accurate manner without negating selfesteem and verbalize relief of anxiety and adaptation to altered body image. OBJECTIVES: After nursing interventions, the patient will be able to: The nurse will: INDEPENDENT: Established therapeutic communica tion to the client as well as to his relatives. To build rapport and trust. May indicate acceptance or no acceptance of situation. Provides opportuniti es for listening to concerns and situations. To show

EVALUATIO N Goal met. After the shift, the client was able to verbalized acceptance on the different physical changes in his situation and display positive views on how he will manage the situation.

Evaluated
level of clients knowledge and anxiety related to the situation.

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 Verbalize

acceptan ce of self in situation. Show positive views regarding on physical changes.

support. Visited the client frequently and acknowledg ed the individual as someone who is worthwhile.

Encouraged
family members to treat client normally.

Compromised family coping related to long term Chemotherapy: ASSESSMENT DIAGNOSI RATIONALE PLANNING INTERVENTION S SUBJECTIVE: Lahat na nga ng aming ariarian naibenta na para lamang sa aking gamutan, as verbalized by the patient. Hindi ko nga alam bakit sa dinami-dami ng pwedeng makaroon ng Compromis ed family coping related to long term Chemother apy Usually supportive primary person [family members (SO)] provides insufficient, ineffective, or compromise d support, comfort, assistance, GOAL: After the shift, the client will further provide opportunity to deal with the situation in own ways. OBJECTIVES: After nursing interventions, the patient will be able to: Verbalize resources The nurse will: INDEPENDENT: Established therapeutic communicati on to the client as well as to his relatives. Assisted family to understand who owns the problem

RATIONALE To build rapport and trust. To develop the role in dealing with current situation.

EVALUATI ON Goal Met. After the shift the client together with his wife was able: To acknowledg e support fro both side.

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ganyang sakit ang asawa ko pa, as verbalized by the wife of the client. OBJECTIVES:
SO attempts assistive and supportive behaviors SO displays sudden outbursts of emotions regarding the treatment.

or encouragem ent that may be needed by the client to manage or master adaptive tasks related to his health challenge.

within themselve s to deal with the situation. Interact appropriat ely with the client, with support and assistance as indicated.

and who is responsible for the resolution, without placing any blame or guilt.

Verbalizatio n that they will fight all throughout and will not surrender.

Risk for deficient fluid volume related to nausea and vomiting secondary to Chemotherapy: ASSESSMENT DIAGNOSI RATIONAL PLANNING INTERVENTION RATIONALE S E Risk factors: Factors influencing fluid needs Fever Nausea Vomiting Risk for deficient fluid volume related to nausea and vomiting secondary to At risk for experienci ng vascular, cellular, or intracellula r dehydratio n. GOAL: After the shift, the client will demonstrate behaviors to prevent development of fluid volume deficit. The nurse will: INDEPENDENT: Established therapeutic nurse-client relationship conveying of caring. To develop a sense of trust. To prevent occurrence of deficit. That may affect fluid

EVALUATI ON Goal Met. After the shift the client was able to show willingness to prevent

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Chemother apy

OBJECTIVES: After nursing interventions, the patient will be able to: Increase water and fluid needs.

Monitored vital signs. Evaluated the nutritional status and clients diet. Monitored I/O balance. Encouraged client to increase fluid intake.

intake. To ensure accurate picture of fluid status. To promote wellness.

fluid deficit by increasing oral intake of fluids.

Risk for infection related to immunosuppressant effects of Chemotherapy: ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION Risk factors: Inadequat e secondary defense Decreased Hemoglobi n Value: Risk for infection related to immunosup pressant effects of Chemothera py At increased risk of being invaded by pathogenic organisms. GOAL: After the shift, the client will identified interventions to prevent/reduce risk of infection. OBJECTIVES: The nurse will: INDEPENDENT: Observed for localized signs of infection at insertion sites of

RATIONALE To assess contributing factors. First line of defense against health care associated infections.

EVALUATION Goal Met. After the end of the shift the client and his caregivers were able to demonstrate proper hand washing before

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103.0 Normal Value: 140-180 Leukopeni a Immnunos uppression Acute Myelogeno us Leukemia

After nursing interventions, the patient will be able to: Demonst rate proper hand washing techniqu e Promote a safe environ ment.

lines. Stress proper hand hygiene by all caregivers between therapies and client. Discussed that safe environme nt can be observed through: Proper disposal of garbage, cleaning the table beside the client. To prevent infection.

and after dealing with the patient.

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